Leading ophthalmologists gathered for an educational dinner hosted by Johnson and Johnson Surgical Vision to explore a pressing question in modern cataract surgery: how far can surgeons push the boundaries when using presbyopia-correcting technologies in patients with ocular comorbidities?
The evening featured Dr Dan Black, a cataract surgeon from Sunshine Eye Clinic (Sunshine Coast, QLD), and Dr Christopher Go, a vitreoretinal surgeon from Vision Eye Institute (Sydney, NSW). Moderator Dr Michael Rossiter-Thornton from Narellan Eye Specialists framed the central question:
“How far can we push the boundary in terms of using presbyopia-correcting intraocular lens (IOL) technologies? Is it something we can only contemplate for patients who are otherwise completely healthy, or can we use it for patients who have corneal or macular disease?”
Dr Rossiter-Thornton noted that patient expectations are evolving, with increasing numbers arriving at consultations already familiar with specific intraocular lens brands, requesting comparisons and justifications.
Dr Black observed patients progressed from “happy to really happy” after bilateral implantation
A New Standard of Care?
Dr Black challenged conventional thinking by suggesting that monofocal lenses, while having served admirably since Harold Ridley’s pioneering work 76 years ago, may now be obsolete. He cited a landmark editorial in the Journal of Cataract and Refractive Surgery authored by Filomena Ribeiro and colleagues¹, which argued that enhanced monofocal lenses –specifically the TECNIS Eyhance from Johnson and Johnson – should be the new standard of care based on Level 1A evidence from 19 clinical studies.
The evidence demonstrated that enhanced monofocal lenses provide superior intermediate vision without compromising distance acuity, contrast sensitivity, or inducing additional dysphotopsia.
Turning to the PureSee extended depth of focus lens, Dr Black highlighted its excellent tolerance to refractive error while maintaining high contrast sensitivity. Data showed that patients with residual refractive error achieved 6/7.5 or better binocular distance acuity in 97% of cases, with none requiring distance correction.
He presented the case of a 70-year-old female with previous myopic laser-assisted in situ keratomileusis (LASIK), higher-order aberrations, and macular changes who achieved excellent outcomes. “High contrast and tolerance to refractive error came to my aid,” Dr Black explained.
Dr Black said tear film optimisation is critical for accurate biometry, recommending patients receive preservative-free lubricants and warm compress instructions three weeks before measurements. He demonstrated how this protocol could reveal hidden refractive errors that would otherwise lead to postoperative surprises.
Extending Boundaries in Retinal Disease
Dr Go, a vitreoretinal surgeon who pioneered premium lens use during his registrar training, addressed theoretical concerns about using presbyopia-correcting lenses in retinal disease patients: reduced contrast sensitivity, potential glare and haloes, refractive surprises, and disease progression.
However, he noted the literature offers few direct comparisons with other IOL technologies. He shared instructive cases, including a trifocal implantation in a patient with vitelliform macular dystrophy who achieved 6/9 distance vision and N6 near vision with high satisfaction, demonstrating that carefully selected patients with retinal pathology could achieve excellent outcomes.
For the PureSee lens, Dr Go highlighted advantages for retinal disease patients: tolerance to residual refractive error, excellent contrast sensitivity, minimal glare and haloes, and minimal distance vision compromise. “I use a simulator to show patients what they’ll get postoperatively,” he explained. “I tell them this is a normal subject, so you might be worse off in all distances, but it gives you an idea of the difference.”
Clinical Insights from Discussion
An interactive session at the conclusion of the event revealed the surgeons’ depth of clinical experience. Dr Rossiter-Thornton queried specific lens comparisons, with Dr Black observing the PureSee lens’ advantageous tolerance to refractive error compared with other extended depth of focus lenses that have suboptimal contrast sensitivity.
Discussion of variable toric axis, particularly at oblique orientations, highlighted ongoing challenges in determining optimal lens alignment. Dr Black acknowledged this represents a significant knowledge gap requiring further study.
Binocular summation with the PureSee lens emerged as particularly noticeable. Dr Black observed patients progressed from “happy to really happy” after bilateral implantation. He recommended limiting monovision to no more than 0.5 dioptres to avoid disrupting summation effects.
Regarding patient selection in retinal disease, both Dr Go and Dr Black counselled conservatism for clinicians beginning to explore these boundaries. “Choose someone with zero comorbidities,” Dr Black advised. “Start in a risk-averse way, pick someone with low expectations. Get a feel of how it works in your practice.”
Dr Go suggested that for patients with mild age-related macular degeneration, extended depth of focus lenses could be offered with appropriate counselling about potential disease progression. He recommended discussing visual goals, trade-offs, and uncertainties given the limited evidence base.
The evening concluded with consensus that while significant evidence gaps remain, carefully selected patients with ocular comorbidities can achieve excellent outcomes with extended depth of focus technology. The PureSee lens emerged as particularly well-suited to challenging cases due to its high contrast sensitivity and tolerance to refractive error, though both speakers reminded the audience of the importance of comprehensive preoperative assessment, meticulous surgical technique, and transparent patient counselling.
Reference
Ribeiro F, Piñero DP, Thomas MD et al. Should enhanced monofocal intraocular lenses be the standard of care? An evidence-based appraisal by the ESCRS Functional Vision Working Group. Journal of Cataract and Refractive Surgery 50(8):789-793, August 2024. doi: 10.1097/j.jcrs.0000000000001479.
Disclaimer
This article reflects the views and opinions of Dr Dan Black, Dr Christopher Go, and Dr Michael Rossiter-Thornton based on their personal experience. The contributors were engaged by Alcon and compensated for their time to prepare and present at the educational event covered in this article.
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