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Cover Stories | June 2020

Premium IOLs in the Post-COVID Era

Recoup some of your 2020 financial loss.

Ophthalmologists who make a living from elective cataract surgery can try to recoup some of the inevitable losses of 2020’s economic disaster by implanting more premium IOLs. Before going any further, let me preface my thoughts with this: The reason for offering presbyopia-correcting IOLs (PC-IOLs) should not be in the interest of the surgeon’s financial needs but rather in the interest of the patient. Always.


It might be the optimist in me, but I have a sense that, after the COVID-19 pandemic, patients will be requesting PC-IOLs at a higher rate than ever. And if the uptake happens to help surgeons recoup some losses, both parties win.

I think that PC-IOLs will be in greater demand in the foreseeable future for the following reasons:

No. 1: Screen time has increased. During the lockdown, individuals have increased their screen time, which has caused some people to become more irritated than before with both glasses and contact lenses. We hear this currently from our own patients.

No. 2: A reduced infection risk is appealing. People are more aware than ever of the infection risks posed by glasses and contact lenses. Contact lens wearers touch their faces and eyes more often than nonwearers, which we know is a risk for infection with pathogens including the coronavirus. The coronavirus can also remain viable on hard surfaces such as metal and glass for at least 7 days, meaning glasses can behave as a vector if they are not frequently washed with soap and water. Further, once contact lenses and glasses are removed from the face, people have the tendency to rub their eyes. Simply put, at this juncture of the pandemic, people are hyper-aware of the benefits of having good vision without the need for prosthetic aids.

No. 3: Face masks interfere with glasses wear. People are wearing face masks regularly for the first time, and glasses wearers especially are irritated by their lenses fogging up during mask use.

No. 4: You only live once. Many patients have a newfound sense of seizing the day. Some are saying to themselves, “I should have had LASIK but was too busy,” or, “I should have chosen multifocal IOLs but I didn’t.” People are realizing that now might finally be the time to do what is in their best interests.

No. 5: Disposable income may be available. Many of our potential patients have not taken salary cuts during the pandemic, especially those who can work from home or are in the information technology sector. They are well paid, and they have not been spending their money on fine dining or exotic vacations this year. These individuals are going to be more inclined to spend on themselves.

No. 6: Baby-boomers who had LASIK 20 to 25 years ago are now entering cataract surgery age. These patients, who had been delighted with their unaided vision before cataract formation, will not tolerate wearing glasses after cataract surgery. Many are going to opt for either blended vision or multifocality.

In a recent survey of 90 experienced cataract and refractive surgeons, most were happy with the performance of PC-IOLs in eyes with previous keratorefractive surgery.1 The mean upper limit for pre-LASIK hyperopia was approximately 3.00 D and for myopia it was -6.00 D. Survey respondents noted several requirements for a good outcome with PC-IOLs, including a good ocular surface, a regular cornea with few higher-order aberrations, and patients’ happiness with their initial LASIK results. Poor prognostic factors included ocular dryness, high corneal aberrations, and dissatisfaction with the original laser vision procedure.


The clinic visit of the future also lends itself to an increase in the use of PC-IOLs. I foresee that the typical 2- to 2.5-hour visit in our clinic will be replaced by a streamlined multistep process that allows more opportunity for patients to understand their options and the risks and benefits of those options. In the clinic visit model we used before the pandemic, it was possible that patients became overwhelmed with too much information in one visit. This might have led them to default to the simplest, most basic option, which is monofocal IOLs.

In contrast, as I see it, the visit of the future will spread out the information we share with patients across three touchpoints.

Touchpoint No. 1: Initial telemedicine consult. Before the patient’s actual clinic visit, a staff member will facilitate a telemedicine consultation to explore the reasons the patient is seeking vision correction. This touchpoint can be valuable to the patient, who is free to take time to digest the educational material presented during the consult. The staff member also informs the patient of the risks and benefits of all potential choices. Your team is integral to the success of this first touchpoint. Personalized and intelligent patient history forms can be emailed or texted to patients, who then simply complete and submit them from their smartphones, tablets, or computers. These forms are structured to determine all the patient’s motivations and expectations, thereby greatly reducing the ophthalmologist’s time required for this first step.

Touchpoint No. 2: Clinical examination. With much of the education and counseling completed during a separate telemedicine consult and the intelligent history form, the clinical examination can be completed much more quickly than before. The purposes of this visit are simply to perform the eye exam and refraction and to obtain the required scans (eg, biometry, OCT, topography, and tomography).

Touchpoint No. 3: Follow-up telemedicine consult. The third touchpoint is also done via telemedicine. In this follow-up consult, the patient can be in the clinic or at home. In the clinic, we have a dedicated room, called the Zoom room, where both parties can feel safe and connected, given that touchpoint No. 2 happened in person. In this consultation, examination results and scans are reviewed, and the patient’s IOL options are discussed. We use a visual behavior monitor (Vivior Monitor, Vivior) that the patient wears for 36 hours prior to the consultation to obtain objective visual data and the company’s Lifestyle Match Index (LMI) to rank the available PC-IOLs against the patient’s personal defocus curve. This approach provides the most objective method to determine suitability and select the best IOL for the patient. This discussion can be done remotely to show the patient his or her scans, demonstrate the IOL selection process though the LMI software, and help the patient to make a final decision.

Prepare for Potential Changes

By Robert J. Weinstock, MD

There are many unanswered questions surrounding patient care in the midst of the COVID-19 pandemic, and therefore it is tough to predict how our patients will feel about premium technologies and procedures in the coming months and even years.

The biggest factor for refractive cataract surgery is that many of our patients are elderly—and, as we know, they are a high-risk group for COVID-19. These patients could get by living another year or 2 with cataracts, but slowly they will return to our practices. The question is this: When they return, will these baby boomers, who are in the retirement phase of their lives, have the finances to elect premium options and procedures? I’m concerned that the answer will be no. We must all be prepared for the current pandemic to potentially change our landscape in refractive cataract surgery.

Before these recent events, I don’t think all of us realized how lucky we’ve been over the past decade. I think taking a moment to pause and appreciate the strides we’ve made in refractive cataract surgery is helpful, and I think our job now is to prepare for the potential changes ahead instead of being surprised by them.

Robert J. Weinstock, MD
  • Private practice, The Eye Institute of West Florida, Largo, Florida
  • Chief Medical Editor, CRST
  • rjweinstock@yahoo.com
  • Financial disclosure: None


One day, the COVID-19 crisis will be over, and life will be more like it was before the pandemic. I believe that some of the strategies and systems we put in place to negotiate the immediate and recovery phases of the pandemic will stand the test of time to become our preferred ways of doing things when COVID-19 no longer rules.

The way we educate patients about PC-IOLs should go beyond the simple “less dependent on glasses” line we often use. Today, we explain to patients that wearing varifocal glasses increases the odds of falling and breaking a hip or leg by 11%.2-6

Cost has always been proposed as a reason for low PC-IOL adoption rates. However, we have conducted multiple informal surveys on patients’ willingness to pay. We have found from these surveys that they are willing to pay, especially when they understand the benefits and know that the most appropriate PC-IOL has been selected for them. Financially, a PC-IOL makes sense because it is a one-time cost. They cost 25% to 50% less than a state-of-the-art hearing aid that must be replaced or upgraded every few years. PC-IOLs represent excellent value.

Positive Outlook for Refractive Cataract Surgery

By Elizabeth Yeu, MD

I am not convinced that COVID-19 will hurt refractive cataract surgery. Here is why.

I’m not an optimist; I’m very much a pragmatist. But there is a psychological component to having poor vision, and many cataract patients have a real fear of losing independence.

This was not even a thought that I had until we started getting phone calls from patients with appointments or surgeries postponed due to the pandemic. Hearing the urgency of their requests and the impact that the lack of a follow-up appointment or a surgery spot had on them was a reality check. We’re going to be OK.

After an initial downturn in surgical numbers—whether it’s 25%, 50%, or 75%—I suspect that cataract surgery volume will jump to closer to 150% before it goes back down to the norm. This is simply because we will be treating the backlog of patients who had to wait to get or reschedule their surgeries.

I am hopeful that the economy will rebound more quickly than we might anticipate because it’s somewhat of an artificial recession. When it does rebound, I suspect that we may see a bump in the number of younger patients getting LASIK and older patients opting to have an advanced-technology procedure simply because what we are experiencing now, with COVID-19, is going to leave an imprint on us as a generation. We are going to lose some of our invincibility; we are being reminded that we’re all susceptible to disease and death. In response, I think we may actually see a greater number of patients adopt premium technology options. More people will be willing to live in the present, to prioritize their health and their vision.

Ophthalmology is poised to rebound successfully. I don’t think that 2020 will end without our surgical volumes leveling out. It will likely happen closer to the third quarter, or maybe the fourth, but it will happen.

Elizabeth Yeu, MD
  • Cataract, corneal and refractive surgeon, Virginia Eye Consultants, Norfolk, Virginia
  • Member, CRST Executive Advisory Board
  • eyeu@vec2020.com
  • Financial disclosure: None


As strange as this might appear to the reader during these challenging times and the subsequent economic storm that we will endure, my prediction is that PC-IOLs will increase their market share in the post–COVID-19 future.

1. Cummings AB. Advances in presbyopic IOLs: Expanding eligibility in previous borderline cases. Paper presented at: ISRS Refractive Subspecialty Day; AAO 2019 Annual Meeting; October 12-15, 2019; San Francisco.

2. Elliott DB. The Glenn A. Fry Award Lecture 2013. Optom Vis Sci. 2014;91(6):593.

3. Lord SR, Dayhew J, Howland A. Multifocal glasses impair edge contrast sensitivity and depth perception and increase the risk of falls in older people. J Am Geriatr Soc. 2002;50:1760-1766.

4. Johnson L, Buckley JG, Harley C, Elliott DB. Use of single-vision eyeglasses improves stepping precision and safety when elderly habitual multifocal wearers negotiate a raised surface. J Am Geriatr Soc. 2008;56:178-180.

5. Johnson L, Buckley JG, Scally AJ, Elliott DB. Multifocal spectacles increase variability in toe clearance and risk of tripping in the elderly. Invest Ophthalmol Vis Sci. 2007;48:1466-1471.

6. Menant JC, St George RJ, Sandery B, Fitzpatrick RC, Lord SR. Older people contact more obstacles when wearing multifocal glasses and performing a secondary visual task. J Am Geriatr Soc. 2009;57:1833-1838.

Arthur B. Cummings, MB ChB, FCS(SA), MMed(Ophth), FRCS(Edin)
  • Consultant Ophthalmologist, Wellington Eye Clinic and Beacon Hospital, Dublin, Ireland
  • Associate Chief Medical Editor, CRST Europe
  • Member, CRST International Board
  • abc@wellingtoneyeclinic.com
  • Financial disclosure: Medical advisory board (Alcon, Vivior), Board of Directors (Alcon)
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