Refractive IOLs

Finding the Right Place on the IOL Continuum

By Eli L. Pratte, MD; Mujtaba A. Qazi, MD; Ibrahim Sayed-Ahmed, MD; and Jay S. Pepose, MD, PhD

Seven years after the first trifocal IOL received US FDA approval in 2019, patients undergoing cataract surgery have more IOL options than ever. The contemporary landscape is a continuum consisting of standard monofocal, enhanced monofocal, nondiffractive extended depth of focus (EDOF), diffractive EDOF, and trifocal IOLs. Gains in functional range can be accompanied by incremental trade-offs in optical quality, including reductions in contrast sensitivity and a greater likelihood of dysphotopsias. Understanding where each platform sits on the continuum of range, optical quality, and dysphotopsias is fundamental to selecting the IOL that best aligns with an individual patient's needs and expectations.

Satisfaction Is a Balance, Not a Ceiling

Early multifocal IOLs required patients to accept meaningful visual compromises in exchange for spectacle independence. Optical quality and visual independence have both improved as lens designs and defocus profiles have evolved, but diffractive optics continue to require trade-offs. Patient satisfaction depends not on maximizing spectacle independence but on achieving the appropriate balance among functional range, optical quality, and dysphotopsias for the individual's lifestyle. Recent patient-reported outcome data suggest that excellent distance visual acuity, strong intermediate visual acuity at approximately 60 cm, and minimal photic phenomena contribute more to overall satisfaction than the sharpest possible near visual acuity.¹

Enhanced Monofocal IOLs

Some patients have visual demands that make the compromises with even the most advanced diffractive lenses impractical. For these patients, an enhanced monofocal IOL may be a more appropriate choice. Reported side effect profiles for these lenses are similar to those of standard monofocal IOLs, but patients' near visual acuity is better with the former.²

A real shift has occurred in refractive cataract surgery. Rather than pursue complete spectacle independence at all costs, a growing number of patients are willing to use spectacles occasionally in exchange for higher contrast sensitivity, fewer dysphotopsias, and more natural visual quality. Instead of diffractive rings, enhanced monofocal lenses harness higher-order aberrations through aspheric surfaces to extend patients' depth of vision without sacrificing their quality of vision.³ The category can be a strong fit for patients in visually demanding occupations, such as pilots,⁴ or those with visually demanding hobbies, such as marksmanship.

Continued platform refinement has broadened defocus performance while maintaining a favorable side effect profile.⁵ For patients who prioritize optical quality, the absence of diffractive rings can provide a favorable dysphotopsia profile, high contrast sensitivity, and high patient satisfaction.

Extended Depth of Focus IOLs

EDOF IOLs are designed to extend functional range while generally maintaining a favorable side effect profile. Optical designs vary considerably. Some use diffractive technology to extend functional range but are designed to minimize dysphotopsias and preserve contrast sensitivity. The latest refractive EDOF IOLs are designed to maximize depth of field while minimizing side effects.⁶

The rapid evolution in both nondiffractive and refractive EDOF designs reflects a philosophy of preserving optical quality while expanding functional range instead of chasing spectacle independence for its own sake. In patients with small pupils under mesopic and photopic conditions, the depth of field and degree of spectacle independence provided by an EDOF lens may rival those achieved with trifocal IOLs, but the dysphotopsia profile is more favorable.⁷ For patients whose occupations or hobbies require high-quality vision and who have a low tolerance for optical side effects, enhanced monofocal and EDOF IOLs are likely the best choices.

Trifocal IOLs

Diffractive multifocal IOLs can provide the greatest degree of spectacle independence. Although the latest technologies are designed to reduce dysphotopsias, this category is generally associated with the greatest side effect burden and the lowest tolerance of lower-order aberrations.^8,9

A careful evaluation of patients' preexisting ocular pathology is imperative. Diffractive optics are less forgiving than other designs in the presence of higher-order aberrations, irregular astigmatism, or reduced contrast sensitivity. Despite these trade-offs, modern trifocal IOLs can achieve high levels of satisfaction in appropriately selected patients.¹⁰

Patients' level of satisfaction depends less on maximizing their near visual acuity than on achieving an acceptable balance between their range and quality of vision.¹¹ Because diffractive optics require the brain to suppress simultaneous out-of-focus images, its ability to adapt successfully likely contributes to differences in satisfaction among patients with similar optical outcomes.

Purpose-Built IOLs

Certain IOLs can be particularly useful in select clinical situations. For example, small-aperture (pinhole) IOLs can be advantageous for patients with highly aberrated corneas.¹² The pinhole effect can deliver a high level of patient satisfaction when the gain in vision and depth of focus outweighs a modest reduction in contrast sensitivity.¹³

This matters because residual refractive error remains a major source of postoperative patient dissatisfaction after cataract surgery.¹⁴ The Light Adjustable Lens (RxSight) permits postoperative refractive refinement. That capability can be particularly useful in patients with preoperative factors that raise the risk of a refractive surprise, such as a history of corneal refractive surgery.¹⁵

Mix-and-Match

Mix-and-match strategies pair different IOL technologies in a patient's two eyes to broaden their functional range while limiting optical side effects.^16-18 Patients with a low tolerance for photic phenomena who prioritize distance visual acuity may benefit from an EDOF IOL in the dominant eye and a diffractive trifocal IOL in the nondominant eye, which may improve their range of vision with only minimal additional dysphotopsias.^16,17

For individuals who are more tolerant of dysphotopsias, implanting a diffractive trifocal IOL in the dominant eye and an EDOF IOL in the nondominant eye can provide excellent near vision without meaningfully compromising their distance vision.^17,18

The Right Lens for the Right Patient

As diagnostic testing continues to improve, successful lens-based surgery will depend less on selecting the newest IOL technology and more on selecting the right lens for the right patient. The preoperative examination and the conversation with the patient remain paramount. Understanding a patient's most frequent visual tasks, occupational and recreational needs, expectations, and tolerance for dysphotopsias allows surgeons to recommend the IOL that best matches the patient's priorities. Ultimately, success in refractive cataract surgery depends on matching the IOL to the individual's needs, lifestyle, and expectations.

1. Lwowski C, Pawlowicz K, Petermann K, et al. Visual and patient-reported factors leading to satisfaction after implantation of diffractive extended depth-of-focus and trifocal intraocular lenses. J Cataract Refract Surg. 2022;48(4):421-428. doi:10.1097/j.jcrs.0000000000000780
2. Greenwood M, Wolsky J, Jemiyo C. Patient-reported outcomes after bilateral implantation of monofocal versus monofocal-plus toric intraocular lenses. Clin Ophthalmol. 2026;20:593547. doi:10.2147/OPTH.S593547
3. Li J, Sun B, Zhang Y, et al. Comparative efficacy and safety of all kinds of intraocular lenses in presbyopia-correcting cataract surgery: a systematic review and meta-analysis. BMC Ophthalmol. 2024;24(1):172. doi:10.1186/s12886-024-03446-1
4. Mendes J, Ribeiro FJ. Cataract surgery and intraocular lens implantation in aviation pilots. J Cataract Refract Surg. 2025;51(4):345-350. doi:10.1097/j.jcrs.0000000000001594
5. Niknahad A, Łabuz G, Muzyka-Woźniak M, Yildirim TM, Son HS, Auffarth GU. An update on intraocular lens technology for presbyopia correction and visual outcomes. Med Sci (Basel). 2026;14(2):299. doi:10.3390/medsci14020299
6. Corbett D, Black D, Roberts TV, et al. Quality of vision clinical outcomes for a new fully-refractive extended depth of focus intraocular lens. Eye (Lond). 2024;38(suppl 1):9-14. doi:10.1038/s41433-024-03039-8
7. Kanclerz P, Toto F, Grzybowski A, Alio JL. Extended depth-of-field intraocular lenses: an update. Asia Pac J Ophthalmol (Phila). 2020;9(3):194-202. doi:10.1097/APO.0000000000000296
8. Chang JSM, Liu SCT, Ma NTC, Ng JCM. Comparative analysis of tolerance to experimentally induced astigmatism with three types of multifocal intraocular lenses. Clin Ophthalmol. 2024;18:139-149. doi:10.2147/OPTH.S429630
9. Schallhorn SC, Hettinger KA, Hannan SJ, Venter JA, Teenan D, Schallhorn JM. Effect of residual sphere on uncorrected visual acuity and satisfaction in patients with monofocal and multifocal intraocular lenses. J Cataract Refract Surg. 2024;50(6):591-598. doi:10.1097/j.jcrs.0000000000001418
10. Teixeira IC, Moscovici BK, Hida WT, de Queiroz Campos MS. Subjective visual quality after bilateral implantation of three diffractive trifocal intraocular lenses: a prospective randomized clinical trial. Indian J Ophthalmol. 2026;74(suppl 1):S40-S45. doi:10.4103/IJO.IJO_2566_25
11. Zhu D, Karki S, Dhariwal M, Soini E, Asseburg C. Patient-reported outcomes of visual disturbances with a trifocal intraocular lens: a meta-analysis. Ophthalmol Ther. 2025;14(2):379-390. doi:10.1007/s40123-024-01085-9
12. Samarawickrama C, Khan M. Implantation of small-aperture IOL in patients with cataract and preexisting corneal comorbidities. Clin Ophthalmol. 2026;20:588341. doi:10.2147/OPTH.S588341
13. Ang RET. Visual outcomes following cataract surgery and implantation of a small-aperture intraocular lens in post-refractive surgery patients. Clin Ophthalmol. 2026;20:571174. doi:10.2147/OPTH.S571174
14. Mönestam E, Wachtmeister L. Dissatisfaction with cataract surgery in relation to visual results in a population-based study in Sweden. J Cataract Refract Surg. 1999;25(8):1127-1134. doi:10.1016/s0886-3350(99)00135-2
15. Jones M, Terveen DC, Berdahl JP, Thompson V, Kramer BA, Ferguson TJ. Clinical outcomes of the light-adjustable lens in eyes with a history of prior corneal refractive surgery. J Cataract Refract Surg. 2024;50(9):936-941. doi:10.1097/j.jcrs.0000000000001481
16. Soscia WL, DeRojas JO, Mathews PM, et al. Clinical performance after implantation of an EDOF intraocular lens in the dominant eye and a presbyopia-correcting intraocular lens in the nondominant eye. J Cataract Refract Surg. 2024;50(6):578-584. doi:10.1097/j.jcrs.0000000000001412
17. Wang L, Meng J, Cheng K, et al. Comparison of visual outcomes between bilateral implantation of multifocal intraocular lens and mix-and-match strategy. J Refract Surg. 2026;42(7):e687-e694. doi:10.3928/1081597X-20260504-04
18. Labiris G, Panagis C, Ntonti P, Konstantinidis A, Bakirtzis M. Mix-and-match vs bilateral trifocal and bilateral EDOF intraocular lens implantation: the spline curve battle. J Cataract Refract Surg. 2024;50(2):167-173. doi:10.1097/j.jcrs.0000000000001336

When Evidence Meets Expectations

By Filomena Ribeiro, MD, PhD, FEBO, and Joaquín Fernández, MD, PhD

A high level of patient satisfaction is not exclusive to any one IOL technology. It can be achieved with different platforms when their benefits and limitations align with a patient's needs, lifestyle, and expectations.

Patient satisfaction therefore depends on more than technological evolution. It also depends on how well we ophthalmologists understand, measure, and communicate the clinical outcomes that matter most to them. A paradigm shift is occurring in which the outcomes that matter most to patients are taking center stage, providing us with a meaningful framework for interpreting the rapidly evolving refractive IOL landscape.

When a patient asks which IOL is best, we begin not with the lens itself but with the life that patient wants after surgery. Is their top priority computer work, night driving, or reading without glasses? How much uncertainty or visual compromise will they accept in exchange for greater spectacle independence?

That conversation has become more complex because the current market includes more than 100 IOL models and overlapping labels such as enhanced monofocal, EDOF, multifocal, and full visual range. These terms may describe an optical concept or a commercial position more clearly than the functional vision a patient can expect.¹

Evidence-based functional classification reframes the question from "What is this lens called?" to "What has this lens been shown to deliver?" Based on the monocular best distance-corrected defocus curve, functional classification divides IOLs into the following groups: partial depth of field (DOFi), including narrowed, enhanced, and extended, and full-DOFi, including steep, smooth, and continuous.²

From Label to Demonstrated Function

IOLs marketed as enhanced monofocal and EDOF, for example, may produce similar clinical outcomes, but lenses sharing the same commercial label may perform quite differently. The International Organization for Standardization and American National Standards Institute have provided a more rigorous basis for the EDOF designation, but demonstrating compliance requires demanding comparative clinical investigations, often involving large samples and a monofocal control.^3,4 Only a minority of available IOLs have completed these qualification pathways, generally according to the regulatory requirements of the markets in which manufacturers intend to introduce them. This raises a fundamental question: Should an IOL be described as EDOF if it has never been evaluated against the standards that define that category?

The question is particularly relevant because such lenses make up most of the available portfolio. In practice, terminology derived from international standards is frequently applied to IOLs that have not completed the corresponding clinical pathway. The term EDOF therefore functions both as a standards-based designation and as a broader commercial label, although these meanings are not equivalent. Many lenses are marketed or commonly described as EDOF without published evidence confirming that they meet the relevant criteria, including evaluation in a comparative study with a monofocal control group and more than 100 participants.^3,4 A label that appears precise may conceal considerable uncertainty about what the lens has actually been shown to deliver.

We have therefore become accustomed to classifying IOLs through something closer to a leap of faith than an evidence-based process. We infer performance from the optical design, the manufacturer's description, or the assigned commercial category. An optical concept, however, does not always translate into a predictable clinical outcome. A label cannot show how a lens performs across the defocus range or identify the trade-offs a patient may experience.

What Functional Classification Adds

Functional classification positions lenses according to demonstrated visual function rather than whether they have been called an enhanced monofocal, EDOF, or multifocal. The system's cut-offs, derived from the historical clinical performance of IOLs, provide a common and transparent framework for interpreting measured outcomes. Evidence has emerged regarding relationships between these categories and outcomes that matter to patients, including their binocular UCVA, spectacle dependence, and even dysphotopsias (F. Ribeiro, MD, PhD, unpublished data, 2026).⁵

For industry, functional classification transforms evidence from a single regulatory hurdle into a continuum. Evidence generation begins on the optical bench, where the expected functional profile can be predicted. Early clinical studies and congress presentations then explore that prediction in patients, peer-reviewed studies provide stronger confirmation, and systematic reviews and meta-analyses consolidate findings across lenses or functional categories. Classification can then evolve as evidence accumulates, with the level of certainty made explicit at each stage.⁶

Making the resource-intensive process described by the International Organization for Standardization and American National Standards Institute the only route to classification has an unintended consequence. Many lenses acquire familiar labels without completing the procedures necessary to demonstrate the corresponding standard.^3,4 Functional classification offers a practical, inclusive alternative. A control group is not required to begin positioning a lens according to its demonstrated functional performance. A well-characterized case series from routine clinical practice, even from a single center, can provide the first evidence, provided that standardized measurements - particularly the monocular best distance-corrected defocus curve - are clearly reported.⁷

Positioning can then be refined as evidence progresses through real-world series, congress presentations, peer-reviewed studies, and meta-analyses. Large randomized controlled trials remain highly valuable and advisable, but they are no longer the only means of generating useful evidence to categorize an IOL.

The transition from EDOF to partial-DOFi extended, for example, is far more than a change in nomenclature. It replaces categories built largely on optical concepts or commercial claims with a clear, progressive, and clinically meaningful body of evidence. More importantly, it shifts our focus from selecting a technology to understanding an outcome.

The Real Paradigm Shift

The future of patient satisfaction will be defined less by the next lens design or claims of the widest range of vision than by our ability to measure what each lens actually delivers, communicate the certainty and trade-offs honestly, and match that evidence to what each patient values. This means asking which evidence-supported option is best for a particular patient. When outcomes, evidence, and expectations converge, satisfaction is no longer left to chance - it becomes an outcome we can understand, predict, and improve.

The true paradigm shift is from asking which IOL is best to determining which evidence-supported option is best for the individual patient.

1. Ribeiro F, Dick HB, Kohnen T, et al. Evidence-based functional classification of simultaneous vision intraocular lenses: seeking a global consensus by the ESCRS Functional Vision Working Group. J Cataract Refract Surg. 2024;50(8):794-798. doi:10.1097/j.jcrs.0000000000001502
2. Fernández J, Koch DD, Barrett GD, Andrade N Jr, Ribeiro F; Functional Vision Working Group. Global consensus on the evidence-based functional classification of simultaneous vision IOLs. J Cataract Refract Surg. 2026;52(3):219-222. doi:10.1097/j.jcrs.0000000000001880
3. International Organization for Standardization. ISO 11979-7:2024. Ophthalmic Implants - Intraocular Lenses - Part 7: Clinical Investigations of Intraocular Lenses for the Correction of Aphakia. 2024. Accessed February 27, 2024. iso.org/standard/79689.html
4. American National Standards Institute. ANSI Z80.35-2018. Extended depth of focus intraocular lenses for presbyopia. Accessed December 14, 2023. webstore.ansi.org/standards/vc%20(asc%20z80)/ansiz80352018
5. Fernández J, Ribeiro F, Dick HB, Rocha-de-Lossada C, Rodríguez-Vallejo M. Navigating the lens labyrinth: a practical approach to intraocular lens classification and selection. Ophthalmol Ther. 2025;14(9):2313-2322. doi:10.1007/s40123-025-01212-0
6. Fernández J, Ribeiro F, Dick HB, Rocha-de-Lossada C, Rodríguez-Vallejo M. An evidence-based pathway from functional classification to intraocular lens specialization: a case example applying the PECO framework. Ophthalmol Ther. 2026;15(7):2501-2513. doi:10.1007/s40123-026-01399-w
7. Fernández J, Ribeiro FJ, Rodríguez-Vallejo M, et al. Standard for collecting and reporting outcomes of IOL-based refractive surgery: update for enhanced monofocal, EDOF, and multifocal IOLs. J Cataract Refract Surg. 2022;48(11):1235-1241. doi:10.1097/j.jcrs.0000000000001013

Beyond the Category

By Jonathan Solomon, MD, FACS

The continued evolution of presbyopia-correcting IOLs has made cataract surgery less about choosing a single best lens and more about matching the optical strategy to the patient. In my practice, the distinctions between enhanced monofocal, EDOF, and multifocal platforms are becoming less absolute. The latest generations of lenses are narrowing the gaps between categories, and mix-and-match strategies allow me to combine their respective strengths.

For me, the most important measure of success is not simply postoperative visual acuity. It is how patients function in the real world and how they feel about the quality of their vision.

The Trade-Off Is Still Real

The fundamental trade-off with presbyopia-correcting IOLs has always been straightforward. Increasing the number or range of useful focal points can increase the potential for optical phenomena such as halos, glare, and starbursts. Trifocal technology has traditionally offered the most complete range of unaided vision, particularly at near, but that expanded range can come at the cost of increased dysphotopsias.

That trade-off matters to patients who drive at night, those who spend a significant amount of time in low-light environments, and those who have a low tolerance for visual artifacts. A technically excellent 20/20 result may not satisfy a patient who perceives bothersome halos around headlights or glare around point sources of light. Conversely, patients who understand the trade-off and place a high value on spectacle independence - particularly for reading - can be extremely satisfied with a trifocal platform.

This is why I consider patient-reported outcomes to be at least as important as patients' Snellen acuity. The question is not, "Can the patient read 20/20?" It is, "What does the patient actually see, and how does that vision affect their life?"

The Line Between Categories Is Blurring

The traditional distinction between an enhanced monofocal IOL and an EDOF lens is blurring. Earlier enhanced monofocal platforms modestly extended functional vision while preserving much of the visual quality associated with conventional monofocal lenses. The latest EDOF designs can provide greater intermediate function without necessarily imposing the same dysphotopsia burden associated with diffractive multifocal optics.

The Tecnis PureSee (Johnson & Johnson Vision) is one example of this evolution. As a purely refractive EDOF design, it is intended to extend patients' range of vision while maintaining high contrast sensitivity and low levels of bothersome visual phenomena. In a clinical study, the PureSee demonstrated improved intermediate and near vision compared with an enhanced monofocal lens while maintaining distance vision and contrast performance.¹

Many of my patients do not need perfect unaided vision at every reading distance. What they want is excellent distance vision, strong intermediate vision for computers and dashboards, and enough functional near vision to handle everyday tasks without feeling that they have traded away the quality of their nighttime vision. The latest EDOF lenses are increasingly capable of delivering that compromise.

Two Eyes, Two Jobs

One of the most rewarding developments has been the ability to move beyond the idea that patients must receive identical optics in both eyes. I have had particular success combining the Tecnis PureSee EDOF platform in the patient's dominant eye with the FineVision HP (BVI Medical) in their nondominant eye. This strategy exploits the different optical characteristics of each platform instead of asking one lens to do everything.

I strive to preserve high visual quality, contrast sensitivity, and a clean distance/intermediate image in the dominant eye. The Tecnis PureSee is attractive in that role. The nondominant eye can then contribute additional near vision through the FineVision HP. The result, in my experience, is a binocular visual system that provides a broad functional range while keeping dysphotopsias to a minimum.

This approach does not simply add the visual capabilities of two lenses together. Binocular summation and neural adaptation allow the visual system to integrate the two optical inputs. The goal is for each eye to contribute what it does best instead of forcing both eyes to provide identical performance at every distance.

Published evidence supports the broader concept. Studies evaluating combinations of EDOF and trifocal IOLs have demonstrated good binocular distance, intermediate, and near performance, with each platform exhibiting different strengths across the defocus range.² Longer-term data with combinations of enhanced monofocal and trifocal IOLs have likewise demonstrated sustained functional vision across multiple distances.³

The Right Lens Is Personal

We are moving away from asking simply, "Which presbyopia-correcting IOL is best?" A more useful question is, "Which combination of optical characteristics best matches this patient's visual priorities?"

For one patient, that may mean a conventional monofocal lens because pristine distance vision and minimal dysphotopsias are paramount. For another, an enhanced monofocal lens may provide the ideal balance. An EDOF lens may be preferable for someone who wants excellent distance and intermediate vision with minimal dysphotopsias. A trifocal IOL may be the best choice for a patient whose top priority is maximum spectacle independence, particularly at near.

Mix-and-match strategies provide another option. Different platforms can be used in each eye to create a binocular visual system that offers more than either lens could provide independently.

My experience with implanting the Tecnis PureSee in the dominant eye and the FineVision HP in the nondominant eye has reinforced this philosophy. I have been impressed by the range and quality of functional vision achieved with this combination, particularly the ability to achieve that range without exposing both eyes to the full dysphotopsia profile of a bilateral diffractive trifocal strategy.

A Broader Toolbox

I see the future of premium IOL surgery as less about increasingly complex lenses and more about increasingly sophisticated customization. The continuing evolution of enhanced monofocal, EDOF, and trifocal platforms is giving surgeons a broader optical toolbox. Our responsibility is to understand the strengths and limitations of each technology and to use that toolbox intelligently.

For me, the goal is simple. It is not merely to give patients more vision but to give them the right vision, with the highest possible quality and the fewest compromises.

1. Kim DY, Park ESY, Park H, et al. Comparative outcomes of the next-generation extended depth-of-focus intraocular lens and enhanced monofocal intraocular lens in cataract surgery. J Clin Med. 2025;14(14):4967. doi:10.3390/jcm14144967
2. Danzinger V, Schartmüller D, Schwarzenbacher L, et al. Clinical prospective intra-individual comparison after mix-and-match implantation of a monofocal EDOF and a diffractive trifocal IOL. Eye (Lond). 2024;38(2):321-327. doi:10.1038/s41433-023-02682-x
3. Danzinger V, Lisy M, Schartmüller D, et al. Three-year comparison of two mix-and-match strategies: enhanced monofocal and trifocal vs enhanced monofocal and trifocal EDOF intraocular lenses. J Cataract Refract Surg. 2026;52(3):275-281. doi:10.1097/j.jcrs.0000000000001808