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 Table of Contents  
Year : 2019  |  Volume : 31  |  Issue : 2  |  Page : 112-120

Advanced technology intraocular lenses: Current trends

Department of Ophthalmology, Chaithanya Eye Hospital and Research Institute, Kochi; Vettam Eye Clinic, Mulanthuruthy, Ernakulam, Kerala, India

Date of Web Publication27-Aug-2019

Correspondence Address:
Dr. Sanitha Sathyan
Vettam Eye Clinic, Perumpilly, Mulanthuruthy, Ernakulam - 682 314, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kjo.kjo_53_19

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This clinical query section discusses the current trends in the practice of advanced-technology intraocular lenses. Experts from across the country share their viewpoints and practice patterns on the subject.

Keywords: Advanced-technology intraocular lens, aspheric intraocular lens, extended depth-of-focus intraocular lens, multifocal intraocular lens, recent advances, toric intraocular lens

How to cite this article:
Sathyan S. Advanced technology intraocular lenses: Current trends. Kerala J Ophthalmol 2019;31:112-20

How to cite this URL:
Sathyan S. Advanced technology intraocular lenses: Current trends. Kerala J Ophthalmol [serial online] 2019 [cited 2020 Jan 27];31:112-20. Available from: http://www.kjophthal.com/text.asp?2019/31/2/112/265505

  Introduction Top

Advanced-technology intraocular lenses (ATIOLs), which include aspheric IOLs, toric IOLs, multifocal IOLs (MFIOLs), and accommodative IOLs, have made a paradigm shift in the management of cataract. The innovations and technological advances in this field have made cataract surgery a truly refractive surgery. Newer IOL technologies including trifocal, quadrifocal, and extended depth-of-focus (EDOF) lenses have been instrumental in providing spectacle-free vision at all distances, along with improvement in optics and aberration profiles.

This section involves leading cataract surgeons from across the country, sharing their clinical experience and concerns regarding the use of ATIOLs.

  Panelists Top

  1. Dr. Mahipal Singh Sachdev, Chairman, Medical Director and Senior Consultant Ophthalmology Centre for Sight Hospital, New Delhi, India
  2. Dr. Mohan Rajan, Director, Dr. Rajan's Eye Hospital, Chennai, Tamil Nadu, India
  3. Dr. Arulmozhivarman, Uma Eye Clinic, Chennai
  4. Dr. Partha Biswas, Director, B B Eye Foundation, Kolkata, West Bengal, India
  5. Dr. Chandrasekhar Wavikar, Medical Director, Wavikar Eye Institute, Maharashtra, India
  6. Dr. Shail Vasavada, Raghudeep Eye Hospital, Ahmedabad, Gujarat, India.

1. Can you elaborate on the preoperative workup of a patient for advanced-technology intraocular lenses at your center?

Dr. Mahipal Sachdev:

Preoperative workup of a patient opting for an AT IOL starts with a thorough medical (general + ocular) history of the patient. The examination begins with the visual acuity and refraction for distance as well as near, followed by intraocular pressure measurement (noncontact). Schirmer's test and contrast sensitivity test are also done. The patient is then referred to an anterior-segment specialist for a thorough examination of the anterior segment on slit lamp. This includes the adnexa (lids, lacrimal system, etc.), cornea and anterior chamber, and pupils. After full dilation, grading of the cataract is again done by the anterior-segment specialist, followed by a dilated refraction. The patient is next sent to a retina specialist, for a thorough examination of the retina up to the ora serrata (indirect ophthalmoscopy). Tests for any posterior-segment findings are conducted, and postcataract visual potential can be prognosticated. A possible need of retinal intervention after cataract surgery is noted. Macular pathology can be one of the limiting factors for determining a patient's inclusion or exclusion for MFIOL implantation. Therefore, detecting macular pathology before cataract surgery is a must. All patients opting for ATIOLs undergo macular optical coherence tomography (OCT).

Patients cleared for surgery by the anterior- and posterior-segment specialists, are then subjected to biometry with the IOL Master 700 (Carl Zeiss Meditec, Jena, Germany) and a specular examination. Astigmatism management is vital to the performance of MFIOLs. All patients undergo corneal topography Pentacam (Oculus Optikgeräte GmbH, Wetzlar, Germany) to measure astigmatism and irregularity of the cornea. In special situations like a mature dense cataract and dense posterior polar opacities, B-mode ultrasound is done.

The treating surgeon, keeping the patients' clinical parameters and expectations in mind, and the IOL Master biometry, gives the patient the possible surgical and IOL options.

Dr. Mohan Rajan:

  • Visual acuity
  • Anterior-segment evaluation
  • Ocular surface evaluation/dry eye workup
  • Intraocular pressure
  • Keratometry
  • IOL Master/Lenstar (Haag-Streit, Bern, Switzerland) biometry
  • Topography
  • Immersion A-scan
  • I-trace (Tracey Technologies, Texas | USA)
  • Specular microscopy
  • OCT macula
  • B-scan if necessary.

Dr. Arulmozhivarman:

I Trace, IOL Master 700, and OCT macula, in addition to detailed anterior- and posterior-segment evaluation.

Dr. Partha Biswas:

We prefer to do a detailed and comprehensive ocular examination for the patient before taking a decision on the type of IOL to be implanted. The following is a brief outline which we follow:

  • Detailed history including any previous intraocular disease/surgery; any history of refractive surgery; and any family history of diseases such as glaucoma, age-related macular degeneration, or retinal pathologies which may require periodic fundus evaluation
  • Understanding the patient's lifestyle including near-work and intermediate-work assessment and nighttime driving and understanding the patient's expectations and personality
  • Tear film assessment tests
  • Detailed slit-lamp examination to rule out any abnormalities of the tear film, cornea, conjunctiva, lid, adnexa, or iris. Lens and zonular status and pupillary dilatation are also noted
  • Intraocular pressure measurement
  • Dilated indirect ophthalmoscopy with 360° scleral depression to rule out any macular pathologies, peripheral retinal abnormalities, or optic nerve pathologies
  • OCT scan of the macular area to confirm a healthy macula
  • Corneal topography to identify any corneal abnormalities, confirm the corneal astigmatism, and assess the mesopic pupillary size
  • Wavefront aberrometry performed for some patients to rule out the presence of significant third- and fourth-order aberrations and measure angle kappa
  • Accurate biometry – We perform both optical and ultrasound biometries, and the keratometry values are again re-checked with the topography
  • Ultimately, the most important preoperative step for these patients is counseling and making them aware about the pros and cons of the IOL options suitable for them and helping them take an informed decision
  • And, the last and the final decision is taken on the table intraoperatively after confirming the posterior capsular and zonular status and ensuring that no intraocular complications have occurred.

Dr. Chandrasekhar Wavikar:

Let us divide the ATIOL into two parts – Toric IOL and MFIOL and quadrifocal IOL (QFIOL).

Workup for MFIOL, in addition to routine cataract workup, consists of the following tests:

  1. Pentacam tomography for three parameters, namely corneal shape, corneal higher-order aberrations, and angle alpha
  2. Macular OCT
  3. Dry eye workup using ocular surface analyzer.

For toric IOL-K (keratometry), readings are taken on at least three instruments, namely Pentacam, IOL Master, and Verion digital marker (Alcon Laboratories, Fort Worth, Texas, USA). Moreover, at least three similar readings from each instrument need to be obtained. Choose one best reading from each instrument for comparison. The K readings may not be same, but the amount of cylinder and axis of cylinder are compared from all the three machines.

Dr. Shail Vasavada:

The most important thing for preoperative checkup is to have adequate time. We have a unique system in the sense that we have a special “Preoperative Clinic,” where a dedicated consultant would be seeing only those patients who have taken a date for surgery. We never do the preoperative checkup in the regular busy outpatient department. Hence, if a patient comes to the clinic and he/she has cataract, and he/she agrees for cataract surgery, then we call him/her again on a separate day in the preoperative clinic.

On the day of preoperative workup, the first investigations that we do are those pertaining to corneal evaluation (manual keratometry, optical biometry, I Trace aberrometry, and Pentacam topography). These are done before putting any eye drops so that we can get accurate corneal readings. We also do a posterior-segment OCT and potential acuity meter measurement for all our patients undergoing cataract surgery as they help to pick up subtle macular pathologies which may affect the postoperative quality of vision for the patient.

Having gone through all these investigations, the consultant would sit along with the patient and his/her relatives and discuss what are his/her requirements and expectations from the surgery, and what is it that we feel would be best suited for him/her with all the possible pros and cons.

2. Which situation would you opt for conventional bifocal intraocular lenses and what is the near addition that you prefer?

Dr. Mahipal Sachdev:

Conventional bifocal IOL is preferred in patients who demand good near vision, do not drive, and cannot afford trifocal IOL (TFIOL). Preferred addition is +4 D in nondominant eye and +3.25 D in dominant eye. In my practice, conventional bifocals are hardly used as my preferred options are trifocal and EDOF IOLs.

Dr. Mohan Rajan:

  • Lifestyle-related needs of the patient
  • Patients who aspire spectacle-free vision
  • Older patients aged >65 years
  • Patients who are not active in profession
  • Patients who use computer meagerly
  • Patients who are housewives/househusbands
  • Patients who read a lot.

Near add: +4.00 D in one eye and +3.25 D in the other eye, which takes care of distance vision, intermediate vision, and near vision.

Dr. Arulmozhivarman:

Conventional bifocal IOLs are used by me in patients who do not accept trifocals. I use a low add +2.75 D in one eye and a high add +4.00 D in the other.

Dr. Partha Biswas:

With the technological advent of TFIOLs, the indications for bifocal IOLs are much less. Conventional bifocal MFIOLs are planned for patients who are motivated for spectacle independence for both distance and near, and

  • Do not have any other intraocular disease
  • Do not have any family history or high risk of developing any retinal pathology which needs periodic monitoring
  • Have a bifocal IOL placed in the other eye
  • Do not have prolonged intermediate vision requirement
  • Have realistic expectations regarding near vision and understand that glasses may be required for prolonged near work.

The near addition is usually tailor-made keeping in mind the near-vision requirements of the patient. Currently, we most commonly use +4.00 D.

Dr. Chandrasekhar Wavikar:

Patients are given the option of TFIOL/QFIOL by default. The option of bifocal is given only if the other eye has bifocal or for budgetary constraints.

The ideal patient for any TFIOL, QFIOL, and EDOF lens is the one who satisfies the following criteria:

  • Corneal higher-order aberrations <0.4
  • Angle alpha <0.4
  • Regular cornea
  • Normal macular OCT
  • No or mild dry eye disease
  • No evidence of any other ocular pathology or amblyopia.

As we all know, angle alpha is the angle between the optical and visual axes of eye. This angle cannot be zero because the fovea is situated temporal to the posterior pole of eye [Figure 1]. We are concerned about visual and optical axes as they pass through the IOL after implantation. As long as both the axes are passing through the innermost ring of MFIOL or TFIOL, the patient will not have any visual disturbance because of this issue. As the optical axis is supposed to pass through the center of the IOL (well-centered IOL will sit properly at the center of bag), angle alpha should be less than the radius of the innermost ring [Figure 2]. [Figure 3] and [Figure 4] shows the correct and incorrect ways of axis marking prior to toric IOL implantation.
Figure 1: Diagrammatic illustration of angle alpha

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Figure 2: Center of the intraocular lens will coincide with optical center of the eye in a well-centered intraocular lens

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Figure 3: Correct method of placing the marks for toric intraocular lens

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Figure 4: Possible sources of error in axis marking

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Patients have to be treated for dryness or  Meibomian gland More Details dysfunction before implantation of any ATIOL.

Dr. Shail Vasavada:

First, the patient should be motivated to be spectacle independent after cataract surgery. From eye point of view, there should not be any major pathology in the cornea or retina/macula. In addition, angle kappa should be <0.6. Astigmatism, if any, needs to be taken care of by choosing a toric bifocal IOL.

For patients for whom reading or near activities are more important compared to far distance and intermediate-vision activities, I would choose a traditional MFIOL with a +3.00 to +3.25 D add power (AcrySof IQ ReSTOR (Alcon-Novartis, USA), Tecnis (Precisionlens, Bloomington, MN, USA), etc.).

However, there are certain patients who would like to be as spectacle independent as possible, but are very active professionals, who drive a lot and have a lot of computer-related activities; for them, our choice would be a low add-power bifocal IOL such as ReSTOR +2.5 D. These IOLs tend to give excellent and crisp distance vision and good-quality vision. However, we do counsel these patients that they would require low-power readers selectively for very fine print reading and that they would require extra light for reading.

3. What is your take on trifocal/quadrifocal technology versus extended depth-of-focus intraocular lenses? Which technology do you prefer and why?

Dr. Mahipal Sachdev:

We, at our center, prefer a TFIOL over an EDOF IOL. Patients who have opted for a TFIOL are spectacle independent in the true sense. In an independently conducted survey among our patients, we found that >90% of our patients with a trifocal (AT LISA, Zeiss, Oberkochen, Germany) are completely spectacle independent. Patients opting for the EDOF lenses are fairly spectacle free, needing glasses for fine small print reading. As far as patient satisfaction goes, we find that patients with TFIOLs are generally more satisfied as compared to those with EDOF IOLs. This is mainly attributed to the lesser incidence of photic phenomena (haloes, glare) in trifocal patients. However, patients with EDOF IOLs are extremely satisfied with their intermediate vision, owing to the enhanced depth of focus at the 40–60-cm range.

If cost is not a limiting factor, we advise a TFIOL, over an EDOF.

Dr. Mohan Rajan:

I prefer EDOF IOL (Tecnis Symfony (Abbott Laboratories, Illinois, USA)) for patients who are active in profession, i.e. younger patients, with the advantages being:

  • Better range of vision
  • Better quality of vision
  • Better contrast sensitivity
  • Less glare and haloes – so patients can drive at night.

I prefer trifocals (PanOptix™) for patients who are not active in profession and who do not drive at night (presence of glare and haloes), with the advantages being:

  • Better near vision
  • Less contrast sensitivity.

Dr. Arulmozhivarman:

As of the present situation, trifocals are the best solution for spectacle independence as they give clear vision over all distances, reduce photic phenomenon, and give better contrast. EDOF IOLs in my opinion are not beneficial as they do not give clear vision for near. These lenses give better contrast sensitivity and reduced photic phenomenon, but do not meet all the three criteria as trifocals do.

Dr. Partha Biswas:

We prefer TFIOLs for patients motivated for spectacle independence at distance-, intermediate-, and near-vision. EDOF IOLs are counseled for patients who mainly require distance and intermediate visual acuities and do not mind wearing glasses for the near. The postoperative contrast sensitivity with EDOF lenses is slightly better than that of TFIOLs, which gives a theoretical advantage for patients accustomed to night driving. Once the pros and cons of both lenses are discussed with the patient, most patients prefer to opt for TFIOLs, and we have good satisfaction rates with them over the last 4 years.

Dr. Chandrasekhar Wavikar:

  • EDOF IOL works well for people who use electronic gadgets for reading. In India, significant population still use printed material for reading for which the person may require minor add reading glasses
  • It is possible to decrease this problem by doing micro-monovision. That means leaving behind slight plus residual in one eye and slight minus residual in the other eye. However, it is not very easy to achieve this in all patients as we all are aware of the limitations of IOL power calculation technology even though we are improving by leaps and bounds
  • There are instances where EDOF lens patients have complained of halos during night driving. Even though halos are not disturbing and hardly any EDOF lens has been explanted, negative dysphotopsia has been the primary reason for the development of EDOF lens
  • Patients implanted with TFIOL have excellent reading vision in addition to the range of vision provided by EDOF lenses. The negative dysphotopsia due to TFIOLs is perhaps lesser than bifocals, and the number of instances where a patient is bothered by these dysphotopsias has reduced significantly
  • As compared to TFIOLs, QFIOLs are supposed to give a continuous range of vision from near to intermediate distance. The negative dysphotopsias are lesser or equal to trifocals. The fourth focus (120 cm) has been redirected to boost up distance vision, thereby improving contrast sensitivity and quality of distance vision. Here, patient satisfaction appears to be better.

Dr. Shail Vasavada:

Currently, there is no “True EDOF IOL” available in the market. Most of them are modifications of low add power diffractive bifocal IOLs, for example: Symfony has been shown to be +1.75 D add diffractive IOL with some modifications in the chromatic aberrations. All of these IOLs are useful for patients who are willing to accept reading glasses and would be satisfied with good distance and intermediate vision with minimal dysphotopsias.

TFIOLs are an extension of bifocal IOLs with the addition of intermediate foci. The earliest TFIOLs (FineVision IOL (PhysIOL, Liège, Belgium), Zeiss) have an intermediate distance focus at 80 cm. It has been shown that 60-cm intermediate distance is more useful for day-to-day activities, and this is probably where PanOptix from Panoptix IOL (Alcon, Fort Worth, USA) has an edge over the other existing trifocals. Fortunately, dysphotopsias have been shown to be equivalent to the traditional bifocal IOLs and not more as many had expected. Hence, now, for any patient desirous of getting maximum spectacle independence, TFIOLs would be our choice, of course after discussing all the possible cons of an MFIOL with the patient.

4. What is the magnitude of astigmatism at which you offer the choice of toric intraocular lenses? Can you share your tips on toric intraocular lens implantation?

Dr. Mahipal Sachdev:

Up to 0.50 D of regular corneal astigmatism is dealt by making surgical incision on the steeper axis of astigmatism. For >0.50 D–1.00 D, we recommend opposite clear corneal incision in patients undergoing microincision cataract surgery and arcuate incisions (approximately 40° arc/0.5 D astigmatism) for patients undergoing femtosecond laser-assisted cataract surgery (FLACS). We must also keep in mind that incisional treatment of astigmatism is unpredictable, and the results are often subnormal, which might also revert back with due course of time.

For astigmatism >1.25 D, we advise toric IOLs. Astigmatism is calculated using the IOL Master 700 and corneal topography (Pentacam).

We also use the Zeiss suite to incorporate the IOL Master readings into the Callisto system by Zeiss. However, as a safety net, we mark all our patients using a bubble marker.

The Callisto system gives real-time markings for the placement of incisions and alignment of the toric IOL.

For the success of toric IOLs, perfect alignment is a necessity. If you are using manual markers, ensure proper preoperative marking in sitting position as studies have shown that eyes may undergo as much as 2°–10° of cyclotorsion when patients lie flat. Complete removal of viscoelastic at the end of surgery should be done. Following the removal of viscoelastic, ensure that the IOL is in the correct axis. Redial into correct position if required. Even after stromal hydration and intracameral antibiotic injection, recheck IOL alignment.

Dr. Mohan Rajan:

An astigmatism of 1.25 D or more would be suggested toric IOL.

Tips on implantation:

  • Keratometry – Manual/IOL Master/Lenstar/topography
  • Biometry – IOL Master/Lenstar/immersion A scan
  • Feeding of data – Barrett toric calculator
  • Marking of the eye – A markerless system – Callisto which is compatible with IOL Master and Zeiss 700 microscope
  • Capsulorrhexis size: 5–5.25 mm, preferably femtorhexis (5.1 mm) using Catalys®.
  • Centricity and shape
  • Consistent surgery – Clear cornea on day 1
  • Cold phaco
  • Viscoat®
  • DisCoVisc®/Healon5®
  • Intraoperative axis marking using Callisto
  • Removal of visco behind the IOL in toto
  • Tight closure of wound, suture if necessary
  • Postoperative nonsteroidal anti-inflammatory drugs, preferably nepafenac.

Dr. Arulmozhivarman:

  • I use the IOL Master 700, Barrett Toric TK formula, and implant Toric IOLs as per the result from the calculations
  • If astigmatism is over 1.00 D, toric IOL is necessary; if it is between 0.5 and 0.75 D, I do limbal relaxing incision (LRI) with a micrometer diamond knife
  • Slit-lamp marking of toric IOL axis is the most accurate
  • I personally use the Callisto eye markerless system.

Dr. Partha Biswas:

The magnitude depends on the procedure the patient is opting for.

  • For conventional phacoemulsification, we prefer to opt for toric IOLs if astigmatism is >1 D
  • For FLACS, we prefer to opt for toric IOLs if astigmatism is >1.5 D because astigmatism of 1.00 D–1.50 D can be easily corrected by the femtolaser LRI.

Tips for toric IOL implantation:

  • Accurate calculation of the amount of astigmatism to be corrected
  • Manual/automated keratometry values should be compared with corneal topography K values
  • Even though posterior corneal astigmatism cannot be accurately calculated at present, its role should be kept in mind while making calculations for toric IOL. We prefer to slightly undercorrect with-the-rule astigmatism and overcorrect against-the-rule astigmatism
  • Another point to consider is that some amount of simple myopic against-the-rule astigmatism actually helps the patient to read unaided at near; hence, leaving against-the-rule astigmatism is always better than with-the-rule astigmatism
  • The actual amount of corneal astigmatism may be checked intraoperatively after cataractous lens extraction using the optiwave refractive analysis
  • Intraoperatively, a toric IOL should always be placed in the bag using hydroimplantation, to avoid rotation of the lens from its intended axis after visco removal. It is imperative to check for the alignment of the axis of the toric IOL before closing the case.

Dr. Chandrasekhar Wavikar:

The decision to implant toric IOL is taken after the calculation of net cylinder (i.e. the sum of anterior and posterior corneal astigmatism derived by vector summation method; it is available on Barrett's toric calculator and also on Wavikar–Saurabh toric tool) and surgically induced astigmatism. This cylinder is the one which needs to be treated. For cylinder between 0.75 D and 1.00 D, LRI is recommended, and for cylinder >1.00 D, toric IOL implantation is recommended.

Tips on toric IOL implantation:

When Verion or Callisto is not used.

Reference marking

When the cornea is marked at 180° or 90°, many errors are introduced because of which the marks may not be at the intended position. A simple method to nullify or minimize these errors is as follows:

  • While taking reading on any instruments or while marking, minute attention has to be given to head position. The head has to be in perfect primary position at all times. This issue becomes more complicated if patient has mature cataract or squint
  • Dry the cornea and place the mark at limbus. The mark has to be quite thin, with clear edges, and should be placed on cornea as well as conjunctiva
  • On slit lamp, use very thin slit of light, so that it passes through the center of the mark where it crosses limbus and the corneal apex. When marked this way, the degree of the slit is the degree of the mark
  • The same principle of line joining the center of the mark as it crosses the limbus to the corneal apex is used to assess the position of the mark. All other precautions need to be the same as explained above
  • Because the planes of marks on the cornea and the dots on the lens are different, a parallax is introduced which may not allow the dots and the marks to overlap. In case of doubt, the eye may be moved from side to side or up to down to check the placement of lens
  • It is very important to remove the viscoelastic under the lens.

Dr. Shail Vasavada:

Few years ago when we started doing toric IOLs, we kept a cutoff of about 1.25 D. Having gained experience over the years, and after the introduction of the Barrett's algorithm and image-guided toric systems like the Verion, we are getting more and more comfortable with correcting lower amounts of preoperative astigmatism. We rely more on the Lenstar and Verion to determine the steep K and the flat K, respectively, whereas we use the Pentacam to confirm the regularity of the astigmatism. We enter the measurements of all the patients in the Barrett's toric calculator, and if it suggests a toric IOL, even T2, we would go ahead and counsel the patient for the same. Hence, I would say that we have no threshold for correcting astigmatism, we would prefer to treat as low an astigmatism as treatable with a toric IOL, and we prefer it over LRIs.

5. Can you brief about intraocular lens technologies in the pipeline, which you think would be promising

Dr. Mahipal Sachdev:

Postoperative refractive adjustment

Perfect Lens (Perfect Lens LLC, Irvine, California, USA): despite its name, the product is not actually an IOL, rather it is a femtolaser system capable of changing the already implanted IOL. It is said to function by changing the hydrophilicity of the IOL, and hence the refractive index. The laser is fired at a 50-μ area inside the IOL, which can change the refraction up to ±10 D. It is also said to offer the advantage to change/reverse multifocality.

Small-aperture intraocular lens

Acu Focus Inc, Irvin, Californis, USA™ has created a monofocal IOL that uses the same principle as a Kamra corneal inlay. The IC-8 IOL is a 6-mm diameter one-piece hydrophobic acrylic lens that incorporates a 3.23-mm doughnut-shaped opaque mask with a central 1.36-mm hole through which light can pass, hence working essentially as a pin hole, increasing the depth of focus.

The Omega Gemini Capsule (Omega Ophthalmics, Lexington, Kentucky, USA)™

It is a three-dimensional device designed to be implanted inside the capsular bag, holding the space open and allowing controlled placement of a refractive lens – and potentially other items – at a known distance relative to the front and back of the eye.

IOLs that are implanted these days are usually 1/5th the thickness of a cataractous lens, which begs the question as to where to place the IOL in a relatively bigger bag. This capsule has multiple shelves on the inner surface, hence eliminating this problem by letting the surgeon place an IOL exactly where it is wanted. The other shelves can also be used to place other drug inserts.

The Tecnis Eyhance intraocular lens (Johnson & Johnson Vision Care, Inc, USA)

It is a new generation of a monofocal IOL, commercially available in certain European countries as of now, with an EDOF for intermediate vision. Hence, a patient can enjoy sharp vision for distance, as well as intermediate, without the need of glasses.

Dr. Mohan Rajan:

  • Light adjustable IOLs (LALs)
  • Smart lens – Thermodynamic hydrophobic acrylic material which reconfigures itself and avoids posterior capsule opacification (PCO)
  • Nu Lens – Sulcus fixated – accommodation +30 D to +50 D
  • Fluid vision lens – Microfluidic technology – accommodation +5 D
  • Liquid lens – Dual-liquid IOL-gravity dependent – lower 3/4th is lower refractive index, whereas upper 1/4th is higher refractive index
  • Rollable IOLs
  • Telescopic IOLs.

Dr. Arulmozhivarman:

Aberration-based IOLs are the future, which will give clear vision over all distances with nil photic phenomenon.

Dr. Partha Biswas:

I think the LALs by (Calhoun Vision Inc Pasadena, California, USA) are the most promising IOLs in the pipeline because they would bring a paradigm shift in refractive cataract surgery by giving an option for postoperative adjustment of power, eliminating the fear of refractive surprise.

Dr. Shail Vasavada:

There are different principles of IOLs that are either in the pipeline or in limited use. These include lenses from FluidVision (PowerVision, Belmont, California) (silicon-filled accommodating IOLs), MiniWell IOL from Miniwell IOL (SIFI Medtech, Catania, Italy) (modifications of spherical aberrations in different zones of the optics to create true EDOF), the LALs from Calhoun (you can modify the postoperative residual refractive error on the IOL by treating it with special lasers), and a couple of other companies that are working on the principle of true EDOF.

The most promising technology according to me would be the LALs, as they allow us flexibility in treating both residual sphere and cylinder postoperatively. They are currently undergoing Food and Drug Administration trials.

6. If you were to undergo cataract surgery, which intraocular lens would you opt for and why?

Dr. Mahipal Sachdev:

Being a surgeon and having active lifestyle, I would want good vision and all distances without any compromise on the quality of vision. I would prefer an acrylic hydrophobic IOL with square edge design with a track record of good visual outcome and minimum PCO. I would choose emmetropia in the dominant eye with micro-monovision allowing me to perform near tasks without aid.

Dr. Mohan Rajan:

I would opt for a monofocal Technis IOL

  • Crystal clear vision for distance
  • No glare and haloes so that I can drive comfortably
  • Contrast vision is good
  • Quality of vision is good
  • Ready-to-wear glasses for near vision or I would prefer one eye plano and the other eye slightly myopic (micro-monovision).

Dr. Arulmozhivarman:

Right now, trifocals.

Dr. Partha Biswas:

I have some amount of myopic astigmatism, and I would definitely like to achieve spectacle independence for distance-, intermediate-, and near-vision. Hence, if I had to undergo cataract surgery with today's technology, I feel I would be most comfortable with toric TFIOLs in both eyes. However, I would like to retain zero-power glasses because glasses have been my loving companion of my waking hours for the last 42 years!

Dr. Wavikar:

I would definitely go for a toric IOL if there is significant cylinder. If I am found a suitable candidate for bifocals or similar lenses on detailed workup, my first choice would be PanOptix. If found unsuitable, my first choice would be Alcon IQ® lens. The performance of IQ lens has been there in front of us for the last 18–20 years. Have found wow factor in patients implanted with PanOptix.

Dr. Shail Vasavada:

Hopefully that should be a few years away! I would prefer a true EDOF IOL, as being a surgeon operating through microscope and using slit lamp, distance vision is the predominant vision that would be needed. On top of that, these IOLs would give good flexibility for intermediate and some flexibility for near vision, and the chances of dysphotopsia would be minimal.


The panelists have shared their practice patterns and clinical experience on the use of ATIOLs. All the panelists have stressed upon the importance of pre-operative assessment in patients opting for ATIOLs. Trifocals, quadrifocals and EDOF lenses have become more popular with the panelists, and the use of conventional bifocal IOLs have come down. Most of the panelists preferred a trifocal IOL over an EDOF IOL, though EDOF IOL was cited as the preferred choice by one of the panelists. Mostly, toric IOL implantation was performed in cases with astigmatism more than 1.00 D to 1.25 D, and most of them use image guiding systems for implantation of toric IOL. All the panelists were hopeful of newer technologies in the pipeline, with potential for reforming the results of cataract surgery by leaps and bounds.

Financial support and sponsorship

None of the panelists have finanacial interest/ sponsorship on the products mentioned.

Conflicts of interest

There are no conflicts of interest.


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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