Cataract surgery is more effective than ever before, thanks to advanced techniques and innovative intraocular lenses (IOLs). These artificial lenses, which get swapped in for the eye's natural lens during surgery, are selected in advance by the patient and the ophthalmologist.
Deciding which lens to choose can be daunting, given the many options available — and the lasting consequences of your decision. An IOL can restore lost vision due not only to cataracts, but also presbyopia, astigmatism or other refractive errors. No single IOL will suit every patient’s needs. So how do you know which lens is best after cataract surgery?
How Do I Choose an IOL?
“A patient’s unique visual requirements, profession, hobbies and budget will all factor into the IOL decision,” said ophthalmologist and Academy member Ronald R. Krueger, MD, MSE, a cataract and corneal surgeon.
Here's what patients and ophthalmologists have to say about the pros and cons of popular IOL types. Once you understand the tradeoffs, you'll be better prepared to discuss the options with your ophthalmologist and come to an informed decision.
IOLs for Distance, Intermediate or Near Vision
Artificial lenses can help correct vision at one or more distances or “zones,” according to ophthalmologist John Hovanesian, MD, an Academy member and specialist in cataract and corneal surgery. The three zones are:
- Distance: Anything beyond an arm’s length away from your eyes (e.g., faces, a television screen and street signs)
- Intermediate: Approximately an arm’s length away (e.g., your car dashboard or a computer screen)
- Near: Anything closer than an arm’s length (e.g., your phone, a book or a magazine)
Most Common IOL: Monofocal Lens
Monofocal lenses are the simplest and least expensive option. A standard monofocal IOL corrects vision in the single zone that you choose. So if you select distance
, for example, you’ll still need glasses to see up close after surgery. The opposite is true if you choose near vision
- Pros: The cost of a monofocal lens is usually covered by Medicare or insurance. This makes it ideal for patients who are on a very tight budget or don’t mind wearing glasses for some activities. In addition, this type of lens is the least likely to cause halos, glare or other visual disturbances at night. A patient with a corneal irregularity like keratoconus may be most comfortable with a monofocal lens.
- Cons: Monofocal lenses won’t completely eliminate the need for glasses for the majority of people, who often need glasses to see at more than one distance.
- What patients say: In a comparative study of IOL implants, 64% of people who selected monofocal lenses said they would choose the same IOL again.
Options for monofocal lenses
Patients who choose monofocal IOLs may opt for a lens with a special feature.
- Toric lens. If you have corneal astigmatism, an irregularity in the curvature of your cornea, you might opt for a toric lens. Astigmatism is very common; about 70% of those with cataracts have it.
- Cost: Toric lenses are not usually covered by insurance and have an additional out-of-pocket cost.
- Considerations: A toric option is available for all types of IOLs, including monofocal and multifocal lenses.
- Monovision. This is where the dominant eye is implanted with a lens for distance while the other eye gets a lens that corrects either near or intermediate vision.
- Cost: Monovision is usually covered by insurance.
- Considerations: This option is normally offered to patients who’ve had past experience seeing this way with contact lenses. It does take some getting used to. It can be difficult to simulate monovision with a cataract in your eye, according to Dr. Hovanesian, so it can be tricky for patients with no prior experience to select this option before surgery.
- What patients say: Despite the period of adjustment, 72% of people who selected monovision say they would choose it again. “For patients over 40 who start out with higher levels of myopia or hyperopia, monovision can be pretty magical,” said Dr. Krueger.
- Light-adjustable lens (LAL). This newer type of monofocal IOL has quickly gained popularity. It is the only type of IOL that can be customized after surgery. With an LAL, your ophthalmologist will be able to adjust the lens for any leftover refractive error after your eye heals. Adjustments are done through a series of office-based light treatment procedures that take a few minutes each.
- Cost: The LAL is considered a premium lens and is not covered by insurance.
- Considerations: An LAL is a good choice for someone who needs precise vision, such as an engineer, pilot, avid fisherman or truck driver. These lenses also allow fine-tuning of vision for people who have had previous LASIK or other corrective eye surgery. However, you may still need to wear glasses for some activities.
- What patients say: In a study of 600 patients, those who received an LAL with post-surgery adjustment were twice as likely as those who received a standard monofocal lens to achieve 20/20 distance vision at 6 months without glasses.
Vision at All Distances: Multifocal IOLs
Multifocal IOLs can correct vision for all three zones: distance, intermediate and near. These are considered premium lenses and are often not covered by insurance.
- Pros: They are a good option for patients who are very active and looking to eliminate the need for glasses. About 92% of patients with multi-focal IOLs say they are now glasses-free.
- Cons: The most significant downside of a multifocal lens is that it can cause you to see halos or glare around bright lights. Most patients eventually adapt to this side effect. But it can continue to be bothersome for about 10% of people. Additionally, “a multi-focal IOL can come with some loss of contrast or ‘waxy’ vision,” according to Dr. Krueger. If you do a lot of driving at night, this may not be the most appropriate lens for you.
- What patients say: About 76% of patients with this IOL said they would choose it again. Patients who have other eye conditions including advanced glaucoma or an ocular surface disease like dry eye tend not to be as happy with a multifocal IOL.
Newest Technology: Extended Depth of Focus (EDOF) IOLs
Extended depth of focus IOLs use one, stretched out corrective zone to improve distance and intermediate vision. Like multifocal lenses, EDOFs are considered premium and may not be covered by insurance.
- Pros: If you want to reduce your dependence on glasses but don’t mind using them to read fine print or see in dim light, EDOF lenses may be a good choice for you.
- Cons: Some EDOF lenses can cause glare or halos.
- What patients say: Overall, 78% of patients with this IOL said they would choose it again. According to a recent study, patients with a non-diffractive EDOF lens are much less likely to notice glare and halos in dim light than patients who have a multifocal IOL. If you are someone who drives a lot at night or is sensitive to these visual disturbances, an EDOF may be a better choice than a multifocal IOL.
It’s important to learn about these lens choices so that you can have a more productive conversation with your surgeon. Listen to your surgeon's recommendations and consider whether they're ideally suited to your unique needs.