Matching the Patient to the Intraocular Lens

Preoperative Considerations to Optimize Surgical Outcomes

Elizabeth Yeu, MD,1 Susan Cuozzo, MA, CMPP2

The intraocular lens (IOL) selection process for patients requires a complex and objective assessment of
patient-specific ocular characteristics, including the quality and quantity of corneal astigmatism, health of the
ocular surface, and other ocular comorbidities. Potential issues that could be considered complications after
surgery, including dry eye disease, anterior or epithelial basement membrane dystrophy, Salzmann nodular
degeneration, and pterygium, should be addressed proactively. Aspheric IOLs are designed to eliminate the
positive spherical aberration added by traditional IOLs to the pseudophakic visual axis. Spherical aberration may
be a consideration with patient selection. Patient desire for increased spectacle independence after surgery is one
of the main drivers for the development of multifocal IOLs and extended depth-of-focus (EDOF) IOLs. However,
no one single multifocal or EDOF IOL suits all patients’ needs. The wide variety of multifocal and EDOF IOLs, their
optics, and their respective impact on patient quality of vision have to be understood fully to choose the
appropriate IOL for each individual, and surgery has to be customized. Patients who have undergone previous
LASIK or who have radial keratotomy and ocular pathologic features, including glaucoma, age-related macular
degeneration, and epiretinal membrane, require specific considerations for IOL selection. Subjectively, patient-
centered considerations, including visual goals, lifestyle, personality, profession, and hobbies, are key ele-
ments for the surgeon to assess and factor into an IOL recommendation. This holistic approach will help surgeons
to achieve optimal surgical outcomes and to meet (and exceed) the high expectations of
patients. Ophthalmology 2021;128:e132-e141 ª 2020 by the American Academy of Ophthalmology. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

The Baby Boomers (the generation born between 1946 and
1964) are filling our examination lanes, and the formation of
a cataract is a common reason for their vision concerns.
Patient expectations continue to soar, even more so with the
Boomers. They are coming in more informed, albeit with
some preconceptions through self-education as well as
anecdotal accounts of a friend or family member who claims
to see perfectly after cataract surgery. This changing patient
demographic leads an active lifestyle and constitutes
approximately one third of the workforce, and approxi-
mately 1 in 10 predict that they will never retire.1 Functional
vision, including a greater range of vision, is of increasing
importance, demonstrated by the fact that nearly three
quarters of Americans age 55 years of age and older own
smartphones.2
To meetdand exceeddpatient expectations, a holistic
approach is critical to optimize outcomes for patients.
Patient selection for intraocular lenses (IOLs) is an art as
well as a science because it is essential to understand
objective and subjective characteristics of the patient.
Objective patient-specific characteristics include medical
history; the health of the eye, especially that of the ocular
surface and macula; corneal power and astigmatism;
biometry; and any other relevant ocular history, such as
prior corneal refractive surgery. Subjectively, patient-
centered considerations, including visual goals, lifestyle,
personality, profession, and hobbies are key elements for
the surgeon to assess and factor into a recommendation for
the patient. When these factors are thoroughly considered,
personalized selection of an IOL can be made, and patients
should have the results they want and expect. This paper
will focus on the importance of the aforementioned patient
considerations as they relate to successful visual and
functional outcomes.
Discussion
Ocular History: Dry Eye Disease
The patient’s ocular history plays an important role in the
patient selection process. Understanding the patient’s
ocular surface is of critical importance because ocular
surface pathologic features can lead to false corneal power
and induced astigmatism.3 Dry eye disease (DED) is
common among many of our patients, often associated
with other systemic and ocular conditions including
allergy,4 diabetes,5 and glaucoma or ocular hypertension.6
Dry eye disease also is common among contact lens
wearers.7 The Prospective Health Assessment of Cataract
Patients Ocular Surface Study evaluated incidence and
severity of DED in 136 patients (272 eyes) scheduled to
undergo cataract surgery. The results showed a high
prevalence of DED in these cataract patients. Overall,
80.9% of the patients in the study had DED leading to a

e132 ª 2020 by the American Academy of Ophthalmology https://doi.org/10.1016/j.ophtha.2020.08.025

This is an open access article under the CC BY-NC-ND license ISSN 0161-6420/20
(http://creativecommons.org/licenses/by-nc-nd/4.0/). Published by Elsevier Inc.
 Yeu and Cuozzo
grade of International Task Force dry eye severity score of
level 2 or higher.8 Pre-existing DED is a significant risk
factor for postoperative DED. Gupta et al9 found that 80%
of patients undergoing a cataract surgery evaluation
had either an abnormal tear osmolarity or matrix
metalloproteinase-9 (MMP-9). A study of patients who
underwent uncomplicated phacoemulsification found that
compared with the patients without dry eye, those in the
dry eye group showed significantly higher postoperative
ocular symptom scores, lower tear film breakup time, and
higher lid margin abnormalities, meibum quality, and
expressibility scores.10 Pre-existing DED also is a signifi-
cant risk factor for persistent postoperative DED. In a study
of patients who underwent uncomplicated cataract surgery,
ocular parameters including high ocular surface disease
index, 1-month postoperative low tear film breakup time,
low meibomian gland orifice obstruction scores, and
increased meibomian gland dropout were identified as risk
factors for persistent DED at 3 months after surgery.11
Unmanaged DED before cataract surgery can lead to a
dissatisfied patient. Objectively, it may lead to refractive
surprises, and subjectively, it may lead to greater DED
symptoms after cataract surgery.12 Epitropoulos et al13
demonstrated that tear hyperosmolarity leads to
significantly greater variability in keratometry values,
which ultimately results in variability in IOL power
calculations and a potential source of a refractive surprise
outcomes. Dry eye disease is best discussed before
surgery to manage patient expectations, rather than after
surgery, when it will be considered more of a
complication. The American Society of Cataract and
Refractive Surgery (ASCRS) Corneal Clinical Committee
developed a consensus-based practical diagnostic ocular
surface disease (OSD) algorithm to aid surgeons in effi-
ciently diagnosing and treating visually significant OSD
before refractive surgery is performed. The DED treatment
plan is based on severity and subtype.12 The evaporative
subtype resulting from meibomian gland dysfunction is
involved in more than 80% of DED cases.14 The Corneal
Clinical Committee noted that by treating OSD before
surgery, postoperative visual outcomes and patient
satisfaction can be improved significantly.12
Figure 1. Example of a baseline corneal topography results in a moderate dry eye patient with central corneal staining. Irregular astigmatism can be seen on
the axial map resulting from ocular surface abnormalities and the central corneal staining. This correlates with the smudgy and irregular mires, especially
centrally, seen on the keratocopic placido image.


Patient Selection for Cataract Surgery
Managing Dry Eye Disease before Cataract
Surgery
A standardized protocol will help to capture ocular surface
issues and DED more accurately before surgery. As
demonstrated by the ASCRS Cornea Clinical Committee,
these examination components should include a standard-
ized symptoms questionnaire (i.e., Standardized Patient
Evaluation of Eye Dryness II), keratometry, evaluation of
signs (i.e., tear osmolarity, MMP-9, meibography), and then
a thorough clinical examination, with a helpful acronym of
LLPP (look, lift, push, pull), followed by vital dye staining
of the ocular surface.12
Placido-disc corneal topography (Fig 1) and infrared
meibography may reveal issues such as meibomian gland
dropout and mild truncation, particularly in patients with
mixed-mechanism DED. Acute preparation for accurate
diagnostics and cataract surgery include perioperative
therapies to improve OSD, although they may be more
aggressive acutely. Steroids can rehabilitate the corneal
surface rapidly15 with hourly preservative-free lubrication
during the day and ointment overnight, with the goal of
improving the corneal staining to obtain accurate preoper-
ative diagnostic imaging. Topical steroids should be used
with caution if risk of an IOP elevation is of concern, such
as in glaucoma patients. When not enough improvement in
corneal staining occurs, a self-retaining cryopreserved
amniotic membrane (PROKERA; Bio-Tissue, Miami, FL)16
may be placed for 1 week, and the optical biometry and
topographies can be performed within 24 hours of
removal of the amniotic membrane. In the interval,
improvement in corneal topography can be observed
(Fig 2). The ocular surface may need more aggressive dry
eye therapy to obtain the most accurate biometric values
possible. Ultimately, chair time to help patients understand
the difference between the baseline progressively
worsening, but consistently blurred, vision caused by
cataracts differs from the fluctuating blurred vision
resulting from DED. It must be communicated that
cataract surgery can worsen DED for months after
surgery12 and chronic DED therapies may be required,
including prescription anti-inflammatory therapy (i.e.,
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 Ophthalmology Volume 128, Number 11, November 2021
Figure 2. Example of corneal topography results after acute perioperative therapies to improve ocular surface disease. The astigmatism is more regular on the
axial map, and there are improved mires on the keratoscopic placido image.
topical cyclosporin 0.05% or 0.09%, lifitegrast 5%), man-
agement of meibomian gland dysfunction with and in-office
intervention (i.e., vectored thermal pulsation), punctal
occlusion, and oral omega fatty acid supplements. If patients
are significantly symptomatic as a result of an acute flare of
DED, normalizing the ocular surface before reinstituting
chronic anti-inflammatory treatment reduces instillation
discomfort.17
Other Ocular Surface Abnormalities
In addition to DED, understanding patients’ ocular surface
pathologic features includes addressing anterior basement
membrane dystrophy (ABMD), epithelial basement
membrane dystrophy, Salzmann nodular degeneration
(SND), and pterygium. These are common sources of false
or induced astigmatism. They also can mimic or exacerbate
DED.18 Anterior basement membrane dystrophy is the most
common corneal dystrophy, affecting an estimated 2% to
3% of the population. Patients of all ages and both
genders can be affected, although the most common age
range at time of presentation is 25 to 75 years of age. The
onset may be spontaneous or may be triggered by a
traumatic injury to the cornea, or recent ocular surgery.
Although the inheritance pattern is autosomal dominant,
not all individuals will be symptomatic. Accordingly, the
absence of a known family history of this disorder does
not exclude the diagnosis.19 Anterior basement membrane
dystrophy sometimes can be challenging to diagnose.
Fluorescein staining can be helpful in identifying subtle
ABMD because the elevations lead to negative staining
results (Fig 3). Anterior basement membrane dystrophy
may or may not require treatment before cataract surgery;
it often depends on the severity and its location. Salzmann
nodular degeneration is a rare, noninflammatory, slowly
progressive, degenerative condition. Gummy gray-white
nodules raised above the surface of the cornea characterize
it.20 Although SND is peripheral, it commonly induces
astigmatism. Studies have shown a high correlation
between SND and chronic ocular surface inflammatory
conditions such as keratoconjunctivitis sicca, exposure
keratopathy, and pterygium.21 Other studies show a high
correlation of SND in patients with ABMD.22 Anterior
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basement membrane dystrophy can be subtle and, if
overlooked, can affect the validity of biometric
keratometric measurements before surgery, resulting in an
inaccurate biometry measurement, incorrect IOL selection,
and reduced visual performance and patient satisfaction.23
Appropriate management of ABMD or SND before
surgery can yield more reliable biometric data for cataract
surgery planning.24 Recommended treatment for ABMD
and SND includes superficial keratectomy with or without
phototherapeutic keratectomy.25
Regarding other corneal abnormalities, the surgical and
IOL options for the cataract patient with a pterygium will
depend on how symptomatic the pterygium is and the
degree to which pterygium is encroaching onto the cornea.
If the pterygium is treated first, full healing should occur
before cataract surgery is performed, which may require 1 to
3 months. If the pterygium encroaches more than 2 mm onto
the corneal surface, astigmatism correction should not be
performed at the time of cataract surgery. Phacoemulsifi-
cation may be performed alone with the pterygium, without
astigmatism correction. The presence of a larger pterygium
may affect the IOL power selection for the patient. Koc
et al26 showed that the recommended IOL power will be less
accurate if a pterygium encroaches more than 2.4 mm onto
the corneal surface.
Intraocular Lens Considerations
Monofocal IOLs, both spherical and aspheric, are the most
commonly used IOLs.27 Aspheric monofocal IOLs are
designed to eliminate the positive spherical aberration
added by traditional IOLs to the pseudophakic visual axis.
Intraocular lens makers have taken different roads to
asphericity, yielding a collection of aspheric lenses that
variously seek to neutralize all (e.g., Tecnis; Johnson &
Johnson Vision), some, or none of the visual system’s
naturally occurring corneal spherical aberration. Some
aspheric IOLs are designed to neutralize only
approximately half of the cornea’s positive aberration
(e.g., AcrySof IQ; Alcon). Others have little to no impact
on spherical aberration (e.g., Crystalens AO;
Bausch þ Lomb). Studies generally have shown greater
contrast sensitivity, particularly in dim light, and better
 Yeu and Cuozzo
Figure 3. Images demonstrating anterior basement membrane dystrophy (ABMD), which sometimes can be challenging to diagnose, with and without
sodium fluorescein (NaFL) staining. Fluorescein staining can be very helpful in identifying subtle ABMD because the elevations lead to negative staining.
performance on night-driving tests with Tecnis compared
with spherical IOLs and, in some cases, also compared with
other aspherics.28,29 Spherical aberration is a consideration
with patient selection. Eyes that have undergone myopic
and hyperopic refractive surgery vary widely in corneal
spherical aberrations. The best-suited IOL for the patient
could be customized and predicted, based on the corneal
higher-order aberrations.
Toric monofocal IOLs and limbal relaxing incisions can
correct corneal astigmatism in patients undergoing cataract
surgery, but toric IOL implantation is more effective and
predictable than limbal relaxing incisions (LRIs).30,31
Additionally, correction of low amounts of corneal
astigmatism with toric IOLs, as low as 0.75 diopter (D),
can lead to a significant decrease in refractive astigmatism
and an improvement in the overall quality of life.32
Satisfactory visual quality has been reported by patients
undergoing toric IOL implantation, and the higher-order
aberrations and contrast sensitivity after toric IOL implan-
tation are similar to those observed with conventional
monofocal IOLs. Toric multifocal IOLs demonstrate good
visual outcomes; however, dysphotopic symptoms such as
glare and halos may limit patient satisfaction.33 Extended
depth-of-focus (EDOF) toric IOLs have been shown to
provide functional distance, intermediate, and near vision in
patients when both eyes are targeted for emmetropia and the
nondominant eye is targeted for slight myopia.34
A patient’s desire for increased spectacle independence
after surgery is one of the main drivers for the development
of multifocal IOLs and EDOF IOLs. However, no one
single multifocal or EDOF IOL suits all patients’ needs. The
wide variety of multifocal and EDOF IOLs, their optics, and
their respective impact on patient quality of vision have to
be understood fully for the appropriate IOL to be chosen for
each individual, and surgery has to be customized.35 Optical
compromises associated with the optic design (diffractive or
refractive) have 3 drawbacks: (1) light splitting, which is
accompanied by contrast sensitivity concerns with any
ocular pathologic features and the need for patients to
have healthy maculas; (2) quality of vision, involving
issues with overall quality or with dim lighting; and (3)


Patient Selection for Cataract Surgery
higher reported frequency of dysphotopsias.36 In a
Cochrane review of multifocal versus monofocal IOLs
after cataract extraction, multifocal IOLs were effective at
improving near vision relative to monofocal IOLs,
although uncertainty remained regarding the size of the
effect. The review concluded that whether that
improvement outweighs the adverse effects of multifocal
IOLs, such as glare and haloes, will vary between people
and that motivation to achieve spectacle independence
may be the deciding factor.37
Specific Patient Populations and Intraocular
Lenses
Previous Corneal Excimer Laser Surgery: LASIK.. Patients
who have undergone myopic LASIK tend to have higher
expectations regarding the refractive outcome. Intraocular
lens calculation for these patients is challenging because it is
difficult for most devices to calculate the true corneal power
after LASIK using the corneal radius of curvature. The
change in the relationship between the anterior and posterior
curvatures of the cornea makes the standardized kerato-
metric index inappropriate.38 When estimating the effective
lens position, it may not be helpful to use the simulated
keratometric value after LASIK, as is done in most of the
third-generation formulas.39 A gap in prediction accuracy
between virgin eyes and eyes that have undergone LASIK
has been documented.40 Intraocular lens calculation in
eyes that have undergone LASIK can be accomplished
using ray tracing with the data from placido disc
tomography.41 In a retrospective study of 25 patients who
underwent LASIK for IOL power determination, custom
ray tracing, including a modified equivalent refractive
index, was an accurate procedure that exceeded the
current standards for normal eyes. The ray-tracing proced-
ure that included an average equivalent refractive index
gave a greater percentage of eyes with an IOL power pre-
diction error within 0.5 D than the Haigis-L (84% vs.
52%).42 Modern IOL formulas, such as the Barrett True-K,
and advanced optical biometers can provide greater refrac-
tive predictability.43e45
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 Ophthalmology Volume 128, Number 11, November 2021
Regarding eyes that have undergone LASIK, presbyopia-
correcting IOLs may be used in certain eyes that have a
well-centered ablation bed, more regular corneal astigma-
tism, and lower amounts of higher-order aberrations. A
recent study that enrolled 71 eyes (43 patients) with
previous successful myopic LASIK found the extended
range-of-vision Tecnis Symfony IOLs (Johnson and John-
son Vision) provided a predictable refractive correction. The
Potvin-Hill and Barrett True-K No History formulas were
considered the most adequate to perform IOL power
calculations in this study.46 A retrospective study evaluated
whether intraoperative aberrometry improved clinical
outcomes of cataract surgery in eyes that have undergone
LASIK with different IOLs implanted in 44 eyes of 31
patients. No statistically significant difference was found
in the percentage of eyes with uncorrected distance visual
acuity (UDVA) of 20/25 or better between multifocal and
monofocal IOL groups (P ¼ 0.41), and more eyes in the
multifocal group achieved a refraction within 0.50 D of
intended (P ¼ 0.03), suggesting that a history of previous
LASIK is not a contraindication to use of multifocal
IOLs.47 Finally, in eyes that have undergone excimer
laser treatment that have irregular corneal astigmatism,
surgeons could consider using the IC-8 (AcuFocus, Irvine,
CA), a first-generation small-aperture lens, to provide
presbyopia correction.48
Previous Radial Keratotomy.. Cataract surgery can be
less predictable refractively in patients with previous radial
keratotomy (RK). It is important to recognize that a
hyperopic outcome occurs early on after surgery because of
flattening of the RK incisions.49 Thus, a surgeon may
consider a longer interval of waiting in between eyes for
refractive accuracy and assessment of first-eye surgical
outcomes. Surgeons can use various “fudge” factors to
provide greater refractive accuracy. For example, a small
study has shown that selecting the minimal keratotomy
values for central corneal curvature and calculation of the
IOL power using the Sanders-Retzlaff-Kraff trial equation
with a reservation of e1.00 to e2.00 D can ensure better the
safety of the procedure and avoid the occurrence of hyper-
opia of more than þ3.00 D.50 The use of intraoperative
aberrometry, careful preoperative diagnostics, or both with
modern IOL formulas, that is, the Barrett True-K or Hai-
gis for RK, can provide more accurate outcomes.51
Advanced optical biometers may be able to image the
total corneal power, and this also can aid more accurate
refractive outcomes, with 43% to 55% refractive
prediction error within 0.5 D.43
Positive clinical outcomes and levels of satisfaction have
been reported in presbyopic patients with previous RK after
presbyopia-correcting IOL implantation, although the studies
are smaller.52 A retrospective review of 24 eyes (12 patients)
showed that EDOF IOLs (Tecnis Symfony IOL; Johnson &
Johnson Vision) can produce good visual outcomes and
satisfaction in patients with a history of RK. Uncorrected
distance visual acuity improved from an average Snellen
equivalent of 20/73 before surgery to 20/33 at an average
final follow-up of 6 months (P ¼ 0.0011), whereas the
average manifest Snellen equivalent improved from þ1.68 D
to e0.18 D (P < 0.0001). At the final follow-up, 15 of 24
e136
eyes (62.5%) were at or within 0.5 D of target refraction,
whereas 20 of 24 eyes (83.3%) were at or within 1.0 D. In
total, 79% of eyes (19 of 24) had a UCVA of 20/40 or better at
distance. In a survey conducted after EDOF implantation,
78% of patients reported satisfaction with their vision after
surgery and 44% of patients reported being spectacle free for
all tasks.53 Where available, this is also another potential
opportunity for surgeons to consider using the first-
generation small-aperture lens IC-8 to provide a range of
vision in those patients with a more irregular cornea.48 The
use of presbyopia-correcting IOLs in eyes that have under-
gone RK is off label, with a smaller body of evidence
available on its use and results thereafter. Thus, surgeons
should exercise caution, using their best judgement based on
patient-specific and corneal characteristics, and advise pa-
tients accordingly.
Other Ocular Pathologic Characteristics:
Glaucoma, Age-Related Macular Degeneration,
and Epiretinal Membrane
In our glaucoma patients, we have very specific consider-
ations for IOL selection. The potential to affect contrast
sensitivity, scotopic or mesopic vision, visual field testing,
and structural imaging, as well as for anatomic features
relevant to glaucoma patients, such as small pupils and
capsular and zonular issues, to affect vision outcomes must
be taken into account when choosing an IOL.54 Glaucoma
patients and ocular hypertensive patients with no disc or
visual field damage who have been stable may be
candidates for multifocal IOLs, but this is a controversial
topic. Multifocal IOLs cause a decrease in contrast
sensitivity, which is worse for near as compared with
distance vision. The mesopic contrast sensitivity is worse
than photopic sensitivity, and the loss is greater at higher
versus lower spatial frequencies after multifocal IOL
implantation. This decrease in contrast sensitivity is
considered to be more so with refractive than diffractive
IOLs.54 Within reason, multifocal or EDOF IOLs may be
used in those patients with milder forms of glaucoma. A
small study examined postoperative outcomes of 15
cataract eyes complicated with coexisting ocular
pathologic features, including glaucoma, that underwent
implantation of a refractive multifocal IOL. Thirteen eyes
(87%) registered 0 or better in corrected distance visual
acuity (VA) and 12 eyes (73%) registered better than 0 in
UDVA. Contrast sensitivity in the eyes of all patients was
comparable with that of healthy participants. No patient
required spectacles for distance vision, but 3 patients
(20%) required them for near vision. No patient reported
poor or very poor vision quality. It was concluded that
with careful case selection, sectorial refractive multifocal
IOL implantation is effective for treating cataract eyes
complicated with ocular pathologic features.55 In contrast,
various studies have demonstrated that multifocal IOLs
can lead to a reduction in visual sensitivity indices seen
on automated visual field perimetry.56,57 Because of a lack
of scientific evidence in the form of large trials on the
impact of multifocal IOLs in glaucoma, decisions
regarding the implantation in a glaucoma patient should
 Yeu and Cuozzo

Patient Selection for Cataract Surgery
be tailored according to the patient’s motivation and the rate
of glaucoma progression.54,58
Age-related macular degeneration (AMD), particularly the
severity of the disease and whether it is exudative or non-
exudative, can lead to vision issues that impact IOL selection.
Blue-light filtering IOLs may be beneficial in protecting the
macula from further progression of AMD.59 Multifocal IOLs
generally are not recommended for patients with AMD
because pre-existing pathologic features are a contraindica-
tion. However, Gayton et al60 demonstrated favorable visual
outcomes with multifocal IOLs in patients with AMD using
a e2.00-D refractive target as a magnification strategy.
Clinical results in patients with severe AMD have been
described for several types of IOLs recommended for AMD,
including an implantable miniature telescope, IOL-VIP
System (Soleko, Pontecorvo, Italy), Lipshitz macular
implant (OptoLight Vision Technology, Herzliya, Israel),
sulcus-implanted Lipshitz macular implant, Fresnel Prism
IOL (Fresnel Prism and Lens Co., Bloomington, MN),
iolAMD (London Eye Hospital Pharma, London, UK), and
Scharioth Macula Lens (Medicontur, Geneva, Switzerland).
Further independent clinical studies with longer follow-up
data are necessary.61 A consecutive case series of 244 AMD
patients undergoing implantation with an extended macular
vision IOL, the iolAMD Eyemax mono (London Eye
Hospital Pharma), found it to be safe in the short to medium
term. Improvements in postoperative corrected distance VA
and corrected near VA exceeded those observed with
standard implants.62
The presence of an epiretinal membrane (ERM) can lead
to more unpredictability with the spherical power of the IOL
selection and its refractive outcome. In a study that
evaluated the accuracy of postoperative refractive outcomes
of combined phacovitrectomy for ERM in comparison with
cataract surgery alone, combined phacovitrectomy for ERM
resulted in significantly more myopic shift of postoperative
refraction compared with cataract surgery alone for both
A-scan and the IOLMaster (Carl Zeiss Meditec, Dublin,
CA). The authors concluded that to improve the accuracy of
IOL power estimation in eyes with cataract and ERM,
sequential surgery for ERM and cataract may need to be
considered.63 Any type of ERM makes a patient a poor
candidate for a multifocal IOL because of the decreased
predictability of spherical power, the ultimate contrast
sensitivity, potential metamorphopsia, and increased risk
for postoperative cystoid macular edema and lower VA
gain.64
Patient Personality and Intraocular Lenses
Patient personalities play a role in the IOL selection process.
The level of visual function and the personality traits
influence patient satisfaction with visual function after
implantation with 4 different multifocal IOLs. The subjective
satisfaction or dissatisfaction of patients after multifocal IOL
implantation is related to certain personality traits: patients
with neuroticism as the dominant personality trait were least
happy with the postoperative outcomes, whereas patients
with conscientiousness and agreeableness as dominant per-
sonality traits demonstrated the highest satisfaction with the
postoperative outcomes.65 The clinical study of 170 eyes of
85 patients was based on a 5-factor inventory personality
evaluation. No statistically significant difference was found in
UDVA (F ¼ 1.6; P ¼ 0.177) and corrected near VA (F ¼ 1.2;
P ¼ 0.30) between the groups 6 months after the surgery.
The answers of the patients with the prevailing neurotic
personality type contradicted the answers given by those with
other prevailing personality types (P < 0.01). The authors
concluded that multifocal IOL implantation helped ensure
better postoperative VA, but some patients were unhappy
with the postoperative outcomes.
To help understand patient personalities better, patient
questionnaire(s) may provide insight into personality type.
In 2004, Dell66 developed a questionnaire to establish a
common vocabulary with patients quickly, to assess how
they wanted to see after surgery, and to determine whether
they were flexible enough to handle the optical
compromises needed for success with presbyopia-
correcting IOLs. He released an update in 2017 that asks
patients about visual preferences, visual tasks, and person-
ality (easygoing vs. perfectionist). Patients with perfectionist
personalities, especially those with perfect visual needs, are
more likely to be dissatisfied with the surgical outcome with
a multifocal IOL implant. Although patients with this type
of personality are not precluded from having presbyopia-
correcting IOLs, preoperative counseling will be needed.
However, patients with more easygoing personalities may
be more likely to accept the compromises in visual quality
they are making for additional spectacle independence.67
Monovision
Pseudophakic monovision goals can be successful with
cataract surgery, but 2 specific considerations should be
taken into account in the patient selection process and
subsequent conversations: (1) pseudophakia leads to abso-
lute presbyopia and (2) the depth perception consequences
of monovision. Monovision generally uses traditional
monofocal lens implants to treat the dominant eye for
emmetropia and the nondominant eye for myopia to
enhance intermediate or near vision. Multifocal IOLs use
refractive or diffractive principles to treat both distance and
near vision with a single lens implant. Generally, distance
vision is similar with implantation of both types of lenses,
near vision was better with multifocal IOLs, and interme-
diate vision seemed to be better in the monovision group.
For patients requiring cataract surgery, both multifocal IOLs
and monovision seemed to address presbyopia with a high
level of patient satisfaction. More patients reported complete
spectacle independence with multifocal IOLs; however, a
tradeoff of more glare and halos were reported by these
patients.68 In a clinical trial to compare spectacle
independence in 212 patients randomized to receive
bilateral multifocal IOLs (Tecnis ZM900; Johnson &
Johnson Vision) or monofocal IOLs (Akreos AO;
Bausch þ Lomb) with the powers adjusted to produce
monovision, patients implanted with multifocal IOLs were
more likely to report being spectacle independent.
However, these patients also were more likely to undergo
IOL exchange than patients implanted with monofocal
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implants with the powers adjusted to give low
monovision.69 A recent retrospective analysis assessed
spectacle independence and patient satisfaction with
pseudophakic minimonovision in patients undergoing
routine bilateral cataract surgery with implantation of an
aspherical aberration-free IOLs (Akreos AO). Pseudo-
phakic minimonovision showed good results for spectacle
independence and high patient satisfaction. It was consid-
ered to be a safe and inexpensive option after bilateral
cataract surgery for correcting distance and intermediate
vision. It also was noted that it may show lower results with
near and night vision, which generally is acceptable, and
that using aberration-free monofocal IOL allows for the
residual normal positive corneal aberration that may
augment the effect of monovision.70
Determining ocular dominance is not always straight-
forward and has implications in monovision corrections.
Many classical tests of ocular dominance exist, but their
results often are contradictory. Several psychophysical tests
were introduced in the late 2000s to measure ocular domi-
nance quantitatively. The results of a recent study showed
weak correlations between psychophysical measures of
strength of dominance with inconsistent identification of the
dominant eye across tests. Agreement on left-eye domi-
nance, right-eye dominance, or nondominance by both tests
occurred for only 11 of 40 observers (27.5%); the remaining
29 observers were classified differently by each test,
including 14 cases (35%) of opposite classification (left-eye
dominance by one test and right-eye dominance by the
other). These observations suggest that effective determi-
nation of ocular dominance and its magnitude remains
insufficient.71
Monovision can sacrifice a degree of depth perception
and clarity. In a recent study, the short-term effects of
optically induced monovision on a depth-discrimination task
for young and older (presbyopic) adults was assessed. Both
groups displayed similar detrimental effects of monovision.
Discrimination accuracy was worse with monovision at the
3-m viewing distance, which involves fixation distances that
are typical during walking. These data suggest that stability
during locomotion may be compromised, a factor that is of
concern for older patients.72 Therefore, a trial with
monovision contact lenses is recommended in potential
surgical patients. A prospective single-center study was
conducted (50 emmetropic presbyopic patients; mean age,
55.4  4.3 years), and each patient wore a þ0.75-D, þ1.50-
D, and þ2.50-D contact lens in the nondominant eye for 1
week. Objective testing after each week included near and
distance VA, distance stereopsis, distance contrast sensi-
tivity, and measurement with 2 different aberrometers of
spherical equivalent, defocus, spherical aberration, and total
higher-order aberrations. Near vision improved with
increased lens power, but distance vision was degraded
objectively and subjectively. The þ1.50-D power provided
optimal near and distance vision for monovision contact lens
wear, whereas it might have limited the range of vision to
the intermediate (66-cm) range. It was concluded that the
objective tests used in this study help to provide a baseline
for evaluation of surgical procedures performed for near
vision enhancement.73
e138
Newer Intraocular Lens Technologies
Newer IOL technologies will help to expand offerings to our
patients. Intraocular lens adjustability is available with the
Light Adjustable Lens (RxSight, formerly Calhoun Vision),
which allows for the refractive characteristics of an
implanted IOL to be altered after surgery to achieve a
customized, patient-specific refraction. In a primary clinical
study of 600 patients, those who received the Light
Adjustable Lens followed by adjustments were twice as
likely to achieve 20/20 distance vision at 6 months without
glasses as those who received a standard monofocal IOL.74
A randomized controlled clinical trial, that included 40
patients with pre-existing astigmatism and visually signifi-
cant cataract, found the Light Adjustable Lens more effec-
tive in achieving target refractions and improving
postoperative UDVA than a standard monofocal lens.75
Furthermore, IOLs with greater pseudoaccommodation
are becoming increasingly available. The AcrySof IQ Vivity
extended vision IOL (Alcon) was approved by the Food and
Drug Administration in February 2020.76 Two large-scale
clinical trials have been conducted; the United States clin-
ical trial included 221 patients who received bilateral im-
plantation of either the AcrySof IQ Vivity extended vision
IOL or AcrySof IQ monofocal IOL. The trial met all its
primary efficacy end points for the Vivity IOL at 6 months
after surgery, including monocular photopic distance-
corrected intermediate VA being superior to a monofocal
IOL (P < 0.001), noninferiority to a monofocal IOL in
monocular photopic best-corrected distance VA of 0.50 D or
more monocular depth of focus at 0.20 logarithm of the
minimum angle of resolution, and monocular photopic
distance-corrected intermediate VA of 0.2 logarithm of the
minimum angle of resolution or more achieved in 72.9% of
eyes. In addition, the Vivity IOL was superior to the mon-
ofocal IOL for monocular photopic distance-corrected near
VA, resulted in statistically significant more eyes with
monocular distance-corrected near VA of 0.3 logarithm of
the minimum angle of resolution or better compared with
the monofocal IOL (95% CI, 40.2% vs. 11.7%), and was
superior to the monofocal IOL (21.6% vs. 3.6%) in
achieving spectacle independence based on findings of the
Intraocular Lens Satisfaction (IOLSAT) questionnaire on
patient-reported visual outcomes. The Vivity IOL demon-
strated safety with low rates of visual disturbances and
adverse events comparable with the monofocal IOL, slightly
reduced monocular mesopic contrast sensitivity at high
spatial frequency, and no clinically relevant decrease on
binocular mesopic contrast sensitivity. The incidence of
severe visual disturbances (e.g., starbursts, halos, and dark
areas) was low (3.8%) and similar between the IOLs. The
percentage of patients reporting severe visual disturbances
declined from immediately after surgery to 6 months after
surgery in both groups.76
The Johnson & Johnson Vision Tecnis Eyhance IOL is
described as a monofocal IOL that gives added intermediate
vision without using EDOF or multifocal technology, and
hence induces no glare or halos.77 The Tecnis Eyhance is
not yet available in the United States. The Eyhance IOL
was evaluated in a prospective, multicenter, bilateral,
 Yeu and Cuozzo

Patient Selection for Cataract Surgery
randomized, 6-month patient- and evaluator-masked clinical
trial. The results of 67 patients with Eyhance were compared
with those of 72 patients in a TECNIS 1-piece model
ZCB00 control group. The trial met its primary end point for
Eyhance for distance-corrected intermediate VA with sta-
tistically significant improvement in binocular intermediate
vision versus the TECNIS 1-piece IOL (1.1 line; P <
0.0001).78 Best-corrected distance VA with the Eyhance
IOL also was comparable (noninferior within 1 line) with
that of the TECNIS 1-piece IOL. No statistically significant
difference was found in the mean monocular and binocular
mesopic, low-contrast (10%) best-corrected distance VA at
4 months between the two lenses. The contrast sensitivity
with glare at 6 months did not show statistically significant
differences at any of the cycles per degree measured at both
mesopic and photopic conditions with glare.78 The photic
phenomena profile of Eyhance was similar to that of the
TECNIS 1-piece IOL with no statistical difference in the
rates of halo, glare, or starbursts observed. The monocular
first-eye defocus curve at 6 months indicated that Eyhance
has a bigger landing zone than the TECNIS 1-piece IOL.78
Next-generation modified monofocal IOLs, such as the
AcrySof IQ Vivity and the Tecnis Eyhance IOL provide an
Footnotes and Disclosures
Originally received: December 20, 2019.
Final revision: August 16, 2020.
Accepted: August 26, 2020.
Available online: August 31, 2020. Manuscript no. D-19-00981.
1 Analysis and interpretation: Yeu, Cuozzo
Department of Ophthalmology, Eastern Virginia Medical School, and
Virginia Eye Consultants, Norfolk, Virginia.
2
Scientific and Strategic Insights, LLC, New York, New York.
Disclosure(s):
All authors have completed and submitted the ICMJE disclosures form.
The author(s) have made the following disclosure(s): E.Y.: Financial sup-
port e Alcon, Allergan, Aurea Medical, Avedro, Avellino, Bausch &
Lomb/Valeant, BioTissue, Beaver Visitec, BlephEx, Bruder, CorneaGen,
Dompe, EyePoint Pharmaceuticals, iOptics, Glaukos, Guidepoint, Johnson
& Johnson Vision, Kala Pharmaceuticals, LENSAR, Merck, Mynosys,
Novartis, Ocular Science, Ocular Therapeutix, Ocusoft, Omeros, Oyster
Point Pharmaceuticals, Science Based Health, Shire, Sight Sciences, Sun,
Surface, TopCon, TearLab Corporation, TearScience, Zeiss, AcuFocus;
Equity owner e BlephEx, CorneaGen, Mynosys, Ocular Science, Oyster
Point Pharmaceuticals, TearScience
HUMAN SUBJECTS: No human subjects were included in this study. The
requirement for informed consent was waived because of the retrospective
nature of the study.
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Author Contributions:
Conception and design: Yeu, Cuozzo
Data collection: Yeu, Cuozzo
Obtained funding: Study was performed as part of regular employment
duties at Virginia Eye Consultants. No additional funding was provided.
Overall responsibility: Yeu, Cuozzo
Abbreviations and Acronyms:
ABMD ¼ anterior basement membrane dystrophy; AMD ¼ age-related
macular degeneration; DED ¼ dry eye disease; EDOF ¼ extended depth-
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OSD ¼ ocular surface disease; RK ¼ radial keratotomy; SND ¼ Salzmann
nodular degeneration; UDVA ¼ uncorrected distance visual acuity;
VA ¼ visual acuity.
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