ESCRS Clinical Trends Series: Presbyopia
In the inaugural edition of the ESCRS Clinical Trends Series, ESCRS Secretary Dr. Joaquín Fernández provides insights on findings from the 2024 ESCRS Clinical Trends Survey, as well as year-over-year trends, offering a detailed look at how members approach presbyopia correction in cataract patients. He also shares his perspective on how these patterns fit into the broader landscape of global eye care, both today and in the years ahead.
Notes on terminology:
The term “presbyopia-correcting IOLs” is not quite accurate and can be considered even controversial. I prefer the term Simultaneous Vision IOLs (SV-IOLs), because what you’re doing is increasing the depth of field of the pseudophakic eye, and providing multiple levels of vision simultaneously. I would prefer to use “presbyopia-correcting IOLs” to phakic IOLs, on which the Presbyopia state of the patient is latent.
This report will use the terms “presbyopia-correcting” and “simultaneous vision” IOL somewhat interchangeably. Notably, the survey questions themselves used the term presbyopia-correcting IOL, but my hope is that, eventually, we as a field move towards the use of the more accurate term SV-IOL.
Trends in SV-IOL Usage
SV-IOL Conversion Rates
According to ESCRS Clinical Trends survey results, the SV-IOL conversion rate among ESCRS members has more than doubled from 7% in 2016 to 16% in 2024 (Figure 1). The increased use of SV-IOLs reflects the convergence of several key factors. Firstly, we’re seeing a rapidly aging population that not only presents more cataract cases but also places greater value on spectacle independence and quality of life. Today’s patients are better informed and more willing to invest in their vision. Secondly, this growing demand is matched by advances in lens technology and a substantial increase in high-quality clinical evidence.
Further Insights
Among survey respondents:
lack confidence in communicating / educating patients about SV-IOL reimbursement 41%
FIGURE 1. What percentage of your CURRENT cataract procedures, among qualified candidates, involve presbyopia-correcting IOLs?
I believe surgeon confidence has also been pivotal. As outcomes are improving, satisfaction is high, and the expanding knowledge base continues to reinforce trust in these technologies. Indeed, cross-analysis of the survey data revealed that those who were more confident in their knowledge level of SV-IOLs had higher levels of SV-IOL conversion rates (Figure 2).
think their use of SV-IOLs will increase in 2025 76%
2. Cross-analysis of conversion rates by self-reported
SV-IOL adoption will likely continue to rise, driven by the rapidly expanding population of over-60 and a growing preference for spectacle independence among cataract patients. However, this growth will likely reach a natural plateau due to persistent barriers such as out-of-pocket costs and clinical exclusions related to ocular comorbidities. While demographic momentum ensures sustained demand, financial and medical eligibility constraints will ultimately limit penetration, preventing these lenses from capturing the majority share of the cataract market within the foreseeable future.
use laser vision correction to correct postoperative residual cylinder in SV-IOL patients 63%
proactively speak about SV-IOLs to some or all qualified patients 75%
FIGURE
SV-IOL knowledge level.
Selecting the Right SV-IOL
Matching SV-IOLs with Patient Needs
Beyond the increased usage of SV-IOLs, the survey found that there have been changes in which specific SV-IOL-categories have been used (Figure 3). In 2016, bifocals and trifocals dominated the field but since then, trifocal usage has remained “flat” whereas bifocals have been overtaken by extended depth of focus (EDF) IOLs.
The first step is identifying the patient’s functional visual needs: individuals who engage in prolonged near work (e.g., reading, crafting, digital device use) may benefit more from Full Depth of Field IOLs (bifocal and trifocals), while those who prioritize intermediate vision (e.g., office work, driving) might be better suited for Partial Depth of Field IOLs (monofocals and EDF). Patients who value high-quality distance vision with limited optical side effects, but still seek some functional range at intermediate, may be candidates for enhanced monofocals, though it’s important to clarify these are not spectacle independent solutions.
“Matching a patient to the most appropriate SV-IOL involves a multidimensional approach that balances clinical metrics with lifestyle priorities.”
FIGURE 3. What type of presbyopia-correcting IOL technology is used in the majority of your presbyopia-correction patients?
In the practice, matching a patient to the most appropriate SV-IOL involves a multidimensional approach that balances clinical metrics with lifestyle priorities, with the main factor being whether the IOL provides sufficient evidence of spectacle independence at the patient’s most functionally relevant distance.
Equally crucial is understanding the patient’s subjective tolerance for optical phenomena like halos and glare, which we explore using preoperative psychometric screening tools and visual expectation questionnaires. This helps us personalize the recommendation and mitigate postoperative dissatisfaction. Then from a clinical standpoint, we assess ocular surface stability, corneal regularity, retinal integrity, preoperative contrast sensitivity, and objective grading of the crystalline lens sclerosis, since these factors can significantly influence postoperative outcomes. We also evaluate the presence of any ocular comorbidities, such as early macular changes or glaucoma, which may contraindicate some SV-IOLs.
Finally, setting realistic expectation is at the core of our decision-making process. In some cases, we use tools like wearable simulators and IOL-specific visual simulations to educate patients on what to expect with various lenses at certain distances, allowing them to make informed choices aligned with both, their lifestyle and their anatomical suitability.
Discussing SV-IOLs with Patients
Barriers to SV-IOL Adoption
The survey revealed that cost to the patient was the biggest concern against more SV-IOL procedures (Figure 4). While the initial out-of-pocket cost of these IOLs can seem significant, I explain to patients that it’s generally a one-time expense that can lead to years—if not decades—of visual freedom and lower ongoing costs, when compared to the cumulative expense of spectacle prescription. Many patients spend €300–€500 every two years on progressive spectacles, and over 10–15 years, this easily exceeds the cost of a presbyopia-
correcting IOL. Focus on helping patients see the value and making sure they have realistic expectations about what the technology can deliver. The key is to reframe the conversation from “cost” to ‘investment in long-term quality of life’.
“Help patients see the value, not just the cost.”
ost to th e p atie n t
C o nce rn o ve r n igh ttime qu ality of vis io n
Concern over loss of contrast visual acuity
Concern o ve r in ad equ ate un aid e d n e ar vis io n
Cannot meet the elevated patient expectations created by a private pay procedure
Concern over inadequate unaided distance vision
Concern over inadequate unaided intermediate vision
FIGURE 4. What do you consider to be your biggest concerns against performing more presbyopia-correcting IOL procedures in your practice? (Select all that apply.)
Concern over nighttime quality of vision was the second biggest concern. Published research has shown that managing these concerns requires a careful balance between several factors: the patient’s preoperative visual quality, their satisfaction with that quality, including their current perception of dysphotopsia and contrast sensitivity and, ultimately, the likelihood of maintaining or even improving visual quality after intraocular lens IOL implantation.1,2
In cases where crystalline lens sclerosis degrades visual performance, SV-IOLs may actually improve preoperative performance. In summary, the surgeon should accompany the patient on their journey from presbyopia to cataract, providing optimal visual correction at each stage, until the appropriate time for surgery with an SV-IOL arrives.
Informing and Educating Patients on SV-IOL Options
The survey found that 75% of ESCRS members proactively discuss SV-IOLs (Figure 5), meaning that 1 in 4 surgeons do not proactively bring them up, at least in their qualified patients. In our practice, the decision to proactively initiate a discussion about SV-IOLs is influenced by many of the same factors that one would use to decide which SV-IOL. Those factors include clinical factors such as degree of corneal astigmatism, ocular surface health, and retinal status, as well as non-clinical factors such their tolerance to potential optical side effects.
I proactively speak about presbyopiacorrecting IOLs to all qualified patients
I proactively speak about presbyopiacorrecting IOLs to some qualified patients
I only discuss presbyopia-correcting IOLs if the patients bring it up
I don’t discuss presbyopia-correcting IOLs
I recommend against it
FIGURE 5. In which of the following scenarios do you discuss presbyopia-correcting IOLs with qualified patients who need cataract surgery and desire spectacle independence?
Patients who express a strong desire for spectacle independence and demonstrate an understanding of the possible trade-offs inherent in multifocal or EDF IOLs depending on their preoperative state of visual quality, are prime candidates for this conversation. Conversely, we are more cautious in patients with irregular corneas, macular pathology, or unrealistic visual expectations.
When we decide to discuss SV-IOLs with patients, emerging technologies are transforming how we educate patients about these lenses. Wearable visual simulators and
The Future of SV-IOLs
There are some exciting emerging technologies, however, what I anticipate over the next 5–10 years is not necessarily a revolution in IOL design, but rather a refinement in how surgeons use current technologies. This will be driven by the continuous growth of high-quality studies that deepen our understanding of each IOL’s functional profile. On this basis, one trend I foresee is surgeons using combinations of IOLs from different functional
Finding Consensus on SV-IOL
Nomenclature
optical bench simulators let patients “test-drive” different IOL options in real-life conditions, improving their understanding of visual outcomes and potential trade-offs. Additionally, software tools and interactive mobile apps help visualize contrast, halos, and vision at different distances. Finally, social media and online patient communities offer firsthand experiences that support education and expectation management. Together, these tools enhance informed consent and help match patients with the most suitable IOL for their lifestyle and visual needs.
categories to expand customization for patients. Additionally, I anticipate more research on micro-monovision, as it’s a practical strategy to enhance near spectacle independence, though it’s important to remember that Full Depth of Field IOLs still offer better outcomes in this regard. Finally, tools like artificial intelligence and augmented reality, might play a role in enhancing efficiency and decision-making in our field.
Today’s discussions around SV-IOLs tend to be controversial, often caused by mixing optical concepts that are difficult to interpret clinically, especially as new technologies seek to differentiate themselves based on theoretical optics. The functional classification aims to resolve this issue.
The proposal led by the Global Functional Vision Working Group composed of ESCRS and ASCRS members, brings an evidence-based structure that classifies IOLs according to the Depth of Field (DOFi) and the visual acuity progression from intermediate to near, both derived from defocus curves under best distance correction. This approach focuses on functional performance, not just optical principles, enabling clearer correlations with patient-centered outcomes like spectacle independence.
This classification system is grounded in two key clinical parameters: the depth of field (DOFi) achieved on the defocus curve under best-corrected distance vision, and the pattern of visual acuity change from intermediate to near. Using these two criteria, six functional categories are defined and grouped into two major classes: Partial Depth of Field (Partial-DOFi) and Full Depth of Field (Full-DOFi).
Within the Partial-DOFi category are three subgroups:
• Narrowed, which includes conventional monofocal lenses offering minimal range extension;
• Enhanced, typically corresponding to enhanced monofocal IOLs that improve intermediate vision modestly;
• Extended, which includes EDF lenses providing broader intermediate performance but still limited near function.
In the Full-DOFi category are three additional subgroups:
• Steep, usually high-add bifocals or certain designs that create a sharper jump from intermediate to near focus.
• Smooth, often associated with modern trifocals that provide balanced vision at far, intermediate, and near;
• Continuous, generally low-add multifocal IOLs with a gentle, uninterrupted transition across distances;
Ultimately, the functional classification helps bridge the gap between IOL technology and real-world performance by translating complex optical properties into clinically meaningful functional expectations, aiding both patient counselling and evidence-based lens selection.
Further Insights
If a ______ patient has no residual refractive error and a healthy ocular surface, what do you believe will be the chances of them having functionally significant visual aberrations at night?
About the Survey
The 2024 ESCRS Clinical Trends Survey was conducted at the 42nd Congress of the ESCRS in Barcelona, Spain. Members and congress attendees also had the option of taking the survey online through the ESCRS website. Questions addressed several areas of clinical practice, including general cataract surgery, astigmatism and toric IOLs, presbyopia correction, glaucoma and MIGS, and corneal refractive surgery.
More than 3,300 ophthalmologists responded to the 147 questions developed and reviewed with the ESCRS leadership team and substantiated by a data scientist. To better identify the educational needs of its members, ESCRS leadership continually refers to the results of these annual surveys and the feedback they elicit. The collected data enhances the educational opportunities featured at the Annual Congress of the ESCRS, the ESCRS Winter Meeting, as well as the ESCRS Clinical Trends Series going forward.
About the Expert
Dr. Fernández has a Medical Doctorate, MSc in Evidence-Based Medicine from the University of Oxford, and PhD in Applied Physics to Science and Technology from the University of Alicante. He is a specialist in Ophthalmology and Anterior Segment Surgery, with a particular focus on refractive surgery, presbyopia, and cataracts.
He is currently the CEO of Qvision and Medical Director of the Ophthalmology Institute of the Vithas Hospital Group in Andalusia. He also serves as a trustee of the Elena Barraquer Foundation, with which he carries out two surgical missions per year to combat preventable blindness due to cataracts in people living in extreme poverty in developing countries. He is an elected member of the Council and Executive Secretary of the ESCRS, where he actively participates in several committees, including the Research Committee, which he chaired, and the Leadership and Innovation Committee.
He chairs the ESCRS Functional Vision Working Group, through which he has led the development of standards for measuring and reporting outcomes in studies involving intraocular lenses, in collaboration with the Journal of Cataract and Refractive Surgery. He also coordinates the Evidence-Based Functional Classification of Simultaneous Vision IOLs, a joint initiative by the ESCRS and ASCRS, aimed at achieving global consensus. He has published over 90 scientific papers in international journals and has contributed to the writing of several specialized books. His work in the field of multifocal intraocular lenses has earned him international recognition, being considered one of the world’s top three experts in the field by ExpertScape.com.
