Patients who desire spectacle independence at all distances are often highly motivated, detail-oriented, and emotionally invested in their outcomes. Success in this situation begins before surgery with rigorous patient selection, detailed counseling about trade-offs, and a clear plan for postoperative optimization. This article describes how I evaluate these patients, guide IOL selection, and set realistic expectations for the neural adaptation and refinement process.

SELECTING THE RIGHT PATIENT

Mindset and Expectations

In addition to evaluating the patient’s ocular surface and overall ocular health, I assess their mindset, expectations, and goals.

When I began implanting trifocal IOLs, I selected patients with minimal astigmatism, healthy ocular surfaces, agreeable personalities, and otherwise pristine eyes. Outcomes were excellent, with a high rate of 20/20 UCVA and strong patient satisfaction. What stood out to me the most, however, was how quickly patients adapted to the technology compared with the bifocal IOLs I had used previously. Neural adaptation was faster, smoother, and more predictable. This early success increased my confidence to expand my use of advanced technology IOLs (ATIOLs) in cataract surgery and, eventually, refractive lens exchange.

Objective Screening

Patients’ level of motivation alone is not sufficient. I evaluate their tear film—the eye’s most powerful focusing element—corneal regularity with topography, corneal higher-order aberrations with aberrometry, and macular health on examination and OCT. Equally important, I confirm that they understand that spectacle independence is a process, not an overnight transformation.

IOL SELECTION: MATCHING TECHNOLOGY TO EXPECTATIONS

Matching Goals and Trade-offs

When I counsel patients, I frame IOL selection as a personalized decision rather than a “best lens” conversation. Trifocal implants are a powerful option for those seeking a full range of vision, and my experience has been positive when the right patients are selected.

I have also achieved excellent outcomes with the Light Adjustable Lens (LAL; RxSight) in patients who are concerned about halos, the longer journey with trifocals, and the longer neural adaptation period associated with multifocality as well as those who have been happy with contact lens monovision for years. Both trifocal and LAL implants are important technologies in my practice, and I use them frequently.

Neural Adaptation and the Time to Satisfaction

What I observed during the US FDA registration clinical trial of my first trifocal lens implant—and what I still see today—is that patient satisfaction often increases over time.¹ Their visual acuity may be excellent in the early postoperative period, but in our clinical trials, the highest patient-reported outcomes occurred around 6 months after surgery. This experience reinforced my belief that, with a healthy ocular surface and accurate refractive target (and a refractive enhancement when necessary), the brain needs time to adapt to multifocality—even when the patient’s UCVA is 20/20 OU.

I remind patients that even a young natural crystalline lens carries meaningful higher-order aberrations. As the lens ages, those aberrations gradually change, and the brain adapts over time. In contrast, a multifocal lens implant introduces optical changes quickly. To adjust, the brain needs a high-quality image (the crisp 20/20 optimization journey) and time (the neural adaptation journey).

Halos: Normalize, Explain, Reassure

I explain that halos are the near/reading component of the implant revealed around lights at night. I tell patients plainly, “That halo tends to improve as your brain adapts.” A small percentage of patients cannot adapt and may require an IOL exchange, but I find this is rare when expectations are set clearly and the surgeon follows through on the full optimization plan.

I also counsel monofocal patients that some individuals become frustrated with the limited near range of a monofocal implant and later request an exchange to a trifocal IOL or LAL. This is why it is critical to match the right implant to the right patient the first time. That said, it is reassuring to know that an IOL exchange is an option when needed. Fortunately, with a high-quality preoperative examination and thorough counseling—whether for advanced technology or standard implants—this remains rare.

REFRACTIVE TARGETING AND A THREE-STEP OPTIMIZATION MODEL

The Three Steps

I tell every ATIOL patient that there are three important steps to optimizing image quality:

• Step No. 1: IOL selection and placement;
• Step No. 2: A refractive enhancement if necessary; and
• Step No. 3: An Nd:YAG laser capsulotomy if necessary.

Enhancement Options and Timing

In traditional cataract surgery, the refractive enhancement is often glasses. In ATIOL surgery, glasses may still be a part of the plan if that approach was agreed upon preoperatively, and some patients are comfortable with this option. Others report disliking bifocals because they feel unstable on stairs or when stepping off a curb, and they prefer a return to the single-vision glasses they wore in their 30s.

Most of my ATIOL patients, however, desire spectacle independence. For these individuals, I work meticulously on IOL power calculations. If their residual refractive error prevents them from achieving crisp 20/20 UCVA, I typically perform a LASIK enhancement. Alternatively, I may perform an astigmatic keratotomy if their spherical equivalent is where I want it to be. PRK remains an option, but I explain preoperatively that the procedure is generally less precise in older patients.

If postoperative image quality is good after IOL implantation, observation is appropriate. If refraction sharpens the image, a refractive enhancement is planned.

Fine-Tuning

When a monofocal IOL patient’s postoperative UCVA is 20/20-2 and they are unhappy with image quality, a refraction is performed. If the image becomes crisp, glasses are prescribed.

A similar commitment should be made to ATIOL patients. If their postoperative UCVA is 20/20-2, they are frustrated, and a manifest refraction sharpens the image, a refractive enhancement, whether by the original surgeon or a trusted colleague, is warranted. I find that, when this possibility is discussed preoperatively, it is usually well accepted.

When Refraction Does Not Solve Blur

If a patient’s UCVA is not crisp, refraction does not improve it, and everything else looks healthy, I begin to suspect the posterior capsule may be to blame. This situation is why I prepare patients in advance for all three steps. I also note that tear film instability is a common contributor to blur, and it is often treated in parallel. An ATIOL works best with an optimized tear film.

CONCLUSION

My job is to listen, perform a careful examination, present both traditional and advanced options, and explain the journey the patient is about to begin. Postoperatively, I am there at each step—to interpret what the patient is experiencing and act when necessary. Most of the time, the issue is not only explainable but demonstrable.

Showing an improvement with refraction, explaining tear film testing and its optical importance, identifying early capsular haze, and revisiting the preoperative discussion about a possible Nd:YAG capsulotomy can be profoundly reassuring to patients. I also discuss preoperatively that vitreous opacities can be a source of blur and may need to be addressed.

The pathway for ATIOLs is not fundamentally different from that for standard implants; the main distinction is how residual refractive error is addressed. With standard monofocal implants, patients typically manage residual error with glasses or contact lenses. With advanced technology implants, we pursue enhancement—either at the cornea (eg, with trifocal IOLs) or by adjusting the optic (eg, with LALs).

Everything else is the same: tear film optimization, Nd:YAG laser capsulotomy when indicated, and, occasionally, management of vitreous opacities.

Clinically identifying the source of frustration and relieving patients’ anxiety through calm explanations can reinforce trust and strengthen the doctor-patient relationship. Cataract surgery with ATIOLs is among the most rewarding additions I have made to my practice in the past 2 decades.

1. Modi S, Lehmann R, Maxwell A, et al. Visual and patient-reported outcomes of a diffractive trifocal intraocular lens compared with those of a monofocal intraocular lens. Ophthalmology. 2021;128(2):197-207.