Latest Development in Extended Depth-of-Focus Intraocular Lenses: An Update : The Asia-Pacific Journal of Ophthalmology

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Latest Development in Extended Depth-of-Focus Intraocular Lenses: An Update

Megiddo-Barnir, Elinor MD*; Alió, Jorge L. MD, PhD*,†

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Asia-Pacific Journal of Ophthalmology 12(1):p 58-79, January/February 2023. | DOI: 10.1097/APO.0000000000000590
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Intraocular lens (IOL) technology for refractive lens exchange, presbyopia, and cataracts has evolved dramatically in the last decades, with the aim of improving visual acuity, reducing possible complications or undesirable side effects, and thus improving the quality of life postoperatively.

As life expectancy is increasing, presbyopia has become a problem. Nowadays, patients have higher expectations not only for distance vision but also for near as well as intermediate vision, with desire for spectacle independence.1–3 Various strategies have been used to compensate for presbyopia, which occurs naturally after cataract surgery.4

Monofocal IOLs are still the most commonly implanted globally in cataract surgery, but monofocal lenses allow only for best-uncorrected visual acuity at a fixed distance and do not offer the levels of spectacle independence demanded by increasing number of patients due to our changing lifestyle. An alternative is the use of mini-monovision, in which the dominant eye is targeted for distance vision and the nondominant eye is aimed for intermediate or near vision.5 Unfortunately, this approach has inherent limitations, including loss of stereopsis.4

Options to correct pseudophakic presbyopia are nowadays diverse. As real accommodative IOLs are unavailable in the market today, the options are based on multifocality or extended depth-of-focus (EDOF) principle. Multifocal (MF) IOLs, diffractive and refractive, are designed to simultaneously provide good distance and near visions but usually provide insufficient intermediate vision.6 With these IOLs, centering of the IOL is particularly important, as a decentered lens can cause disturbing lower and higher order aberrations.7–9 Furthermore, they can be associated with visually significant photic phenomena and reduced contrast sensitivity (Fig. 1) that can significantly impair the optical quality of vision and therefore the overall satisfaction of patients.10–14

Diffractive (A) and refractive (B) multifocals illustrations of optics and limitations (including loss of incident light and due to transitions, loss of contrast, and unwanted optical effects).

As such, there was a gap to fill with an IOL that offers a good balance between uncorrected distance, intermediate vision, and photic phenomena.

To overcome the issues of MF IOLs, there is a growing interest toward the technology of the EDOF lenses that are designed to correct presbyopia by providing spectacle independence over a wider range, than classic monofocal IOLs,15,16 while minimizing optical phenomena as halos and glare, which are common to diffractive bifocal or trifocal lenses, or refractive IOL with higher near addition as +3.00 D.16–19

Pseudoaccommodation is the increase in depth of focus in a pseudophakic eye beyond that predicted by the optical properties of the IOL.20 Pseudoaccommodation is due to the static optical properties of the pseudophakic eye independent of ciliary muscle actions on the IOL.21,22 Increased levels of pseudoaccommodation may be used to increase the depth of focus and accommodative amplitude in the presbyopic population. The most frequent factors that positively influence pseudoaccommodation include corneal and IOL wavefront aberration, astigmatism,23–27 and small pupil size.25 Based on the understanding of inherent pseudoaccommodation, these pseudoaccommodative mechanisms are employed in different types of the EDOF lenses.

The EDOF Concept

The basic optical principle of the EDOF lenses is to create a single, continuous, elongated focal point from far and near to enhance the depth of focus, to enhance intermediate and near visual performance, on the contrary to monofocal IOLs (in which light is focused on one single point) or MF IOLs (having 2 or 3 discrete points),28 without the overlapping of images that constitute both refractive and diffractive multifocality (Fig. 2), thus eliminating the halo effect; ideally, these IOLs should enhance intermediate and near visual performance, while minimally affecting distance vision. EDOF IOLs provide a continuous range of focus, avoiding the presence of secondary out-of-focus images.29,30 In this way, EDOF IOLs differ from the MF IOLs which show at each of their foci secondary out-of-focus images corresponding to the rest of the foci, which originate halos and whose characteristics depend on the lens design (especially the magnitude of the addition) and size of the pupil.3 EDOF lenses focus elongation has a consequence of a linear distribution of the light energy instead of going all this energy to one or different foci. Consequently, there is a potential decrease of contrast sensitivity with a degradation of the retinal optical quality of the image. Therefore, it should be noted that increased depth of field might have a tradeoff, which is a degradation in vision quality. Particularly, if the aberration magnitude is too large, it leads to a reduction in distance image quality, overlapping of the perceived images, with dysphotopsia phenomena.31

The extended depth-of-focus (EDOF) concept. A monofocal lens produces a single focal point (top). A near-centered multifocal lens simultaneously creates superimposed images of distance and near zone foci (middle). EDOF lenses broaden the depth of focus to encompass a broader range of foci (bottom). For simplicity, the model assumes paraxial rays of monochromatic light source to avoid confounding aberrations.

What Is Not an EDOF Lens

During recent years, large number of lenses claiming EDOF capabilities have emerged and reached the market, hence the American Academy of Ophthalmology (AAO) released a consensus statement32 with requirements for the evaluation and categorization of IOLs as an EDOF lens. It should be noted that as per the AAO Task Force Consensus Statement for Extended Depth of Focus Intraocular Lens, the use of EDOF rather than EDOF has been recommended. For convenience purpose in this review, we shall keep the EDOF nomenclature since it is more commonly used today in clinical practice.

To name a lens an EDOF IOL, the optical profile must be continuous, without a change in transition equally refractive or diffractive. All the lenses that employ chromatic aberration (CA) or have a diffractive-hybrid profile, or an additional power to increase the near vision, with no pure continuous range of vision on the optical bench, are not pure EDOF IOLs.4,28

Types of EDOF Optics

Currently, there are various optical designs in use to achieve an EDOF. As published by Alió,33 EDOF lenses can be subdivided into 5 categories (Table 1). Lenses that are based on spherical aberration (SA) provide an exaggerated manipulation of the SA, in either a positive or a negative direction, which increases the depth of focus proportional to the magnitude of the induced aberrations. Small aperture lenses use the pinhole effect to extend the range of visual acuity. These first 2 groups are pure EDOF lenses. The third group are really MF lenses, either refractive or diffractive, endowed with a low addition for near. The fourth group are hybrid EDOF-MF lenses in which manipulation of SA is combined with modest power addition for near vision. The fifth group comprises lenses which use a variation in the geometry of a central zone in the optic of the lens to cause either a greater refractive power in the center and decreasing refractive power in the periphery, or modulation of the wavefront to cause an increase in depth of focus.

TABLE 1 - Classification of the EDOF Lenses By Types, Showing the Different Characteristics of Each IOLs
Lens model Manufacturer Material Positioning Total diameter Optic diameter Technology Pupil dependent Add/EDOF Spherical aberration Power range Toric version
Type 1
 Mini Well Ready SIFI, MEdtech 1-piece, biconvex, double aspheric copolymer, hydrophilic with a hydrophobic surface, double square edge, UV filter Bag 10.75 mm 6.00 mm Refractive Yes +3.00 D 0 to +30.00 D (0 to +10.00 D increments 1.00 D, +10.00 to +30.00 D increments 0.50 D) Yes
Type 2
 IC-8 AcuFocus 1-piece, hydrophobic acrylic, polyvinylidene fluoride carbon nanoparticles, UV filter Bag 12.50 mm 6.00 mm Small aperture No +3.00 D
Type 3
 Lentis comfort LS-313 MF15 Teleon surgical 1-piece, asymmetrical, sector-shaped near vision anterior segment, biconvex aspheric posterior surface, acrylic hydrophilic with hydrophobic surface, square edge, properties, UV filter Bag 11.00 mm 6.00 mm Refractive No +1.50 D −10.00 to +36.00 D (increments 1.00 D) No
 Acunex Vario An6 V Teleon surgical 1-piece, biconvex, aspheric, acrylic hydrophobic, UV and blue light filter Bag 12.50 mm 6.00 mm Refractive No? +1.50 D 0.0 +10.00 to +30.00 D (increments 0.50 D) No
 AT LARA 829 MP Carl Zeiss Meditec 1-piece, aspheric, hydrophilic acrylate with hydrophobic surface properties Bag 11.00 mm 6.00 mm Diffractive Yes 0.95 D, +1.90 D 0.0 −10.00 to +32.00 D (increments 0.50 D) Yes
Type 4
 FineVision Triumf POD L GF PhysIOL 1-piece, biconvex aspheric, hydrophobic acrylic, UV and blue light filter Bag 11.40 mm 6.00 mm Diffractive Yes +1.75 D, +3.50 D +10.00 to +35.00 D (increments 0.50 D) Yes
 Tecnis Symfony ZXR00 Johnson & Johnson 1-piece, biconvex, anterior wavefront-designed aspheric surface, posterior achromatic diffractive surface, echelette design, hydrophobic acrylic, square edge, UV filter Bag 13.00 mm 6.00 mm Diffractive Yes +1.75 D +5.00 to +34.00 D (increments 0.50 D) Yes
 Lucidis Swiss Advanced Vision, SAV-IOL SA 1-piece, aspheric, hydrophilic acrylic, square edge Bag 10.80 mm, 12.40 mm 6.00 mm Refractive Yes +3.00 D +5.00 to +30.00 D (increments 0.50 D) Yes
 Supraphob Infocus Appasamy associates 1-piece, hydrophobic acrylic yellow chromophore, square edge, UV filter Bag 13.00 mm 6.00 mm Refractive Independent up to 4.75 mm +3.50 D +7.00 to +30.00 D (increments 0.50 D) No
 EDEN Swiss Advanced Vision, SAV-IOL SA 1-piece, hybrid multizone (refractive, diffractive, aspheric), hydrophilic acrylic, square edge, UV protection cutoff at 370 nm Bag 10.80 mm, 12.40 mm 6.00 mm Refractive, diffractive Yes +3.00 D +5.00 to +30.00 D (increments 0.50 D) Yes
 Harmonis Swiss Advanced Vision, SAV-IOL SA 1-piece, hybrid multizone (refractive, diffractive, aspheric), hydrophilic acrylic, square edge, UV protection cutoff at 370 nm Bag 10.80 mm, 12.40 mm 6.00 mm Refractive, diffractive Yes? Add +2.50 to +3.50 D (by 0.25 D steps) EDOF 1.00 to 2.00 D (by 0.50 D steps) +5.00 to +30.00 D (increments 0.50 D) No
 Synergy ZFR00 Johnson & Johnson 1-piece, biconvex, wavefront-designed aspheric surface, diffractive posterior surface, hydrophobic acrylic, square edge, UV and violet filter Bag 13.00 mm 6.00 mm Diffractive No +3.00 D +5.00 to +34.00 D (increments 0.50 D) Yes
Type 5
 EyHance ICB00 Tecnis Johnson & Johnson 1-piece, biconvex, continuous, higher order aspheric anterior surface, without rings, hydrophobic acrylic, square edge, UV filter Bag 13.00 mm 6.00 mm Refractive monofocal-EDOF Yes +1.5 D −0.27 +5.00 to +34.00 D (increments 0.50 D) No
 AE2UV/ZOE Eyebright Medical/Ophthalmo Pro GmbH 1-piece, posterior convex, aspherical optic, hydrophobic acrylic, glistening-free, Miyata Grade Zero, square edge, UV filter Bag 13.00 mm 6.00 mm Refractive monofocal -EDOF Yes? +0.75 to 1.00 D −0.20 +5.00 to +36.00 D (increments 0.50 D) No
 Synthesis PLUS Cutting Edge 1-piece, aspheric, hydrophilic, acrylic, square edge, UV filter, blue light filter option Bag 11.00 mm (0 to 15.0 D) 10.70 mm (15.25 to 22.0 D) 10.50 mm (22.25 to 32.0 D) 6.00 mm Refractive monofocal-EDOF Yes? +1.50 D 0 to +32.00 D (0 to +10.00 D increments 0.50 D, +10.25 to +32.00 D increments 0.25 D) No
 Acrysof IQ Vivity DFT015 Alcon 1-piece, nondiffractive, wavefront shape, biconvex, aspheric, based on SN60WF monofocal lens, hydrophobic acrylate/methacrylate copolymer, UV and blue light filter Bag 13.00 mm 6.00 mm Refractive monofocal-EDOF No +1.50 D −0.20 +10.00 to +30.00 D (increments 0.50 D) Yes
 LuxSmart Bausch & Lomb 1-piece, nondiffractive, aspheric, hydrophobic, square edge, UV filter, violet filter option Bag 11.00 mm 6.00 mm Refractive Yes? +1.75 D 0 to +34.00 D (0 to +10.00 D increments 1.00 D, +10.00 to +34.00 D increments 0.50 D) Yes
 RayOne EMV Rayner 1-piece, biconvex (positive powers), aspheric anterior surface, rayacryl hydrophilic acrylic, square edge, benzophenone UV absorbing agent, UV 10% cutoff is 380 nm Bag 12.50 mm 6.00 mm Refractive-monovision Relatively pupil-independent Up to 2.25 D EDOF with 1.00 D offset +10.00 to +30.00 D (increments 0.50 D) Yes
Extended depth-of-focus (EDOF) intraocular lens (IOL) that were discontinued of use are not presented in the table.
D indicates diopter; UV, ultraviolet.


Type 1—Pure EDOF IOLs SA Based

SA in EDOF Lenses

Monochromatic aberrations are subdivided into 2 broad classes: lower order aberrations (LOAs) and higher order aberrations (HOAs). LOAs include myopia (positive defocus), hyperopia (negative defocus), regular astigmatism, and nonsignificant aberrations known as first-order aberrations, such as prisms and zero-order aberrations (piston). HOAs include secondary astigmatism, coma, trefoil, quadrafoid, and SA. Each HOA has its own effect on the image quality of an optical system; the presence of HOAs and particularly SA, coma and secondary astigmatism can improve depth of focus.34 The Zernike polynomials are a useful way of describing the HOA in the eye.35 SA (Z4,0) is an aberration associated with focal length difference between central and marginal ray where the light enters the lens.28 When negative, incoming parallel rays will focus further away as they are located away from the optical axis (Fig. 3). For any given eye, the Zernike coefficient may vary widely, however, most HOAs average to zero with the notable exception of corneal SA, with a mean value of +0.31±0.135 μm for a 6.00 mm pupil size.36 This positive corneal SA can be corrected within a limited degree by a negative SA IOL. The benefit of neutralizing the corneal SA is achieving a sharper focus light and consequently a sharper vision at a single given distance. In contrast, although the presence of HOAs degrade the quality of vision, it must be noted that some presence of HOAs (particularly SA, coma, and secondary astigmatism) improves depth of focus37 and this is the main optical mechanism in EDOF lenses. Instead of correcting the SA of the cornea, an aspherical surface can be used to produce a focus zone with low change in intensity and spot size. EDOF lenses based on asphericity, modulate the asphericity of the optic to increase the depth of focus. This can be achieved by increasing the negative asphericity of the anterior or posterior surface of the lens, generating a more negative SA (Fig. 4).

Diagram showing a lens with positive spherical aberration, negative spherical aberration and chromatic aberration.
Schematic illustration demonstrating how increased negative asphericity of the anterior surface of a lens in the form of progressive surface flattening will cause the peripheral rays to refract further away from the paraxial focus due to reduced angle of incidence. This results in extended depth of focus at the expanse of a blur of the image as a result of the defocused rays.

It must be understood that EDOF lenses based on asphericity have a more negative asphericity than that needed to compensate (partially or fully) for the corneal SA and these lenses use the asphericity primarily to increase the depth of focus.4

Inducing SAs in EDOF IOLs means that incoming light waves are extended in a longitudinal plane. The elongated focus eliminates the overlap of near and far images, and theoretically eliminates the halo effect. The tradeoff is a decrease in the quality of the retinal image, which limits their performance as there is a degradation of the visual quality. Therefore, the near-vision capability is usually limited to about 1.00 D.28

CA in EDOF Lenses

White light is comprised of different wavelengths of visible light, ranging from red (700 mm) to violet (400 mm). As it passes through an optical system, each of its component wavelengths refracts or bends independently, depending on the refractive index of that particular material for each wavelength. By Snell’s law, faster-moving longer wavelengths bend less than slower-moving shorter wavelengths, dispersing the various wavelengths to different focal points along the optic axis.31

CA is a consequence of focal length difference between the visible spectrum of different colors of light. The human cornea induces CAs, as blue light is diffracted more than red light. In pseudophakic eyes several factors can affect CAs induced by the IOL, increasing or decreasing it, depending on the properties of the IOL. Among these factors are the dispersion of the IOL material38 and the IOL optical design.39

In optics, the dispersion is expressed by the Abbe number which is the variation of the refractive index versus the wavelength of light, with high values indicating low dispersion.

The optical design also has an impact on the CA of the eye. A refractive optic maintains CA induced by the cornea; with this lens the final ocular CA will increase. In contrast, a diffractive optic can reverse CA as red blends more than blue. Consequently, a diffractive IOL can minimize the CA in the eye.

The reduction in CA causes an increase in the contrast sensitivity and therefore an extended depth of field and better quality of vision,40,41 although occasionally at the cost of some photic phenomenon. This is the one of the principles pure EDOF lenses and some of the additional EDOF effect IOLs, including the diffractive EDOFs, are based on.

  • Mini Well Ready (SIFI; Medtech):
  • Mini Well Ready is an aberration-based single-piece progressive EDOF IOL with a double aspherical optic design (Fig. 5). The overall diameter is 10.75 mm with 4 closed-loop haptics with 5-degree angulation and with an optical surface diameter of 6.00 mm. The IOL is made of copolymer, includes an UV filter, and is also available in a toric version. The optics of the Mini Well has 3 zones: an outer monofocal zone and the inner and middle zones where different SAs of opposite signs are applied to increase depth of focus of the lens (Fig. 6). The innermost zone is 1.80 mm wide and has a positive SA, creating the intermediate focus. The middle zone is 3.00 mm wide and has a negative SA, contributing to near focus. The outermost zone is a monofocal optic with a diameter of 6.00 mm that is responsible for creating the far focus. The lens features an equivalent addition of +3.00 D corresponding to a spectacle plane addition of +2.40 D. Power ranges from 0 to +30 D (0.50 D increments from +10.50 to 30.00 D).30,42 In clinical study by Giers et al42 the binocular defocus curve showed a broad range of plateau reaching 4.00 D (between +1.50 and −2.50 D) with a visual acuity of 0.20 logMAR or better. However, the patients still preferred a median intermediate reading distance of 62.80 cm. Patients reported a high rate of spectacle independence and satisfaction in everyday life and little to no dysphotopsia. In other studies, Savini and colleagues29,30 showed that the increased depth of focus was provided through 2.00 D defocus, with best performance at −1.00 and −1.50 D. Although the lens manifests good optical quality at a large defocus range, the modulation transfer function characteristics are strongly affected by the pupil size.43 Evaluation of the retinal image quality of different premium IOLs by Alió et al44 found a drastic significant reduction in PSFw2 Strehl ratio values in the Mini Well group.
  • Wichterle Intraocular Lens—Continuous Focus (Medicem):
  • The Wichterle intraocular continuous focus lens (WIOLCF) (Fig. 7) is categorized as an EDOF bioanalogical lens. The lens has a polyfocal optic and the IOL should theoretically change shape during the accommodation effort.45 However, that possible accommodation, resulting from a deformation of the lens secondary to a ciliary body contraction that induces an increase on the thickness and a reduction of both anterior and posterior radii of the lens, is only one of 3 mechanisms ensuring vision at all distances in this type of lens. The other 2 are represented by polyfocality, which provides high depth of focus due to a hyperbolic optics and pseudoaccommodation, enabled by a combination of polyfocality and pupillary reflex.

Mini Well Ready (SIFI; Medtech). A pure extended depth-of-focus lens based on changes in peripheral and mid-peripheral asphericity.
Mini Well extended depth-of-focus (EDOF) intraocular lens (IOL) basic principle: the incident beam is not divided to create a single elongated focal point.
Wichterle intraocular continuous focus lens (WIOLCF). A bioanalogical extended depth-of-focus lens.

The lens material is a negatively charged hydrogel from a methacrylic copolymer with a water content of 42%. It has a large diameter optic of 8.60 to 8.90 mm with a posterior hyperbolic surface that resembles the crystalline lens. Another characteristic of this IOL is that it has no haptics. The hyperbolic posterior surface of the IOL provides infinite foci. The refractive power of the lens decreases from the center to the periphery as does the thickness of the lens that changes from 1.70 mm in the center to 0.80 mm in the periphery.45 The lack of haptics and large dimensions of the optic of the IOL were supposed to be beneficial, however, few reports of IOL instability associated with this design have been published46–48; the IOL tilt and dislocation had a characteristic pattern and was present despite the absence of trauma.47 In few initial studies, patients achieved good distance, intermediate, and near visual acuity49 with reasonable amount of HOAs.50 Nevertheless, despite the commercial hype that accompanied this group of lenses, some of these lenses, as the WIOLCF, turned out to be a clinical failure. The WIOLCF ceased production in 2018 due to its poor results related to the excess of SA induced by the lens.33

Type 2—EDOF IOLs Based on the Pinhole Effect

The pinhole principle is another optical mechanism allowing a greater depth of focus. From the equation presented by Campbell over 50 years ago, it can be deduced that with increasing pupil size, the depth of field and the depth of focus decreases.51 Moreover, the Stiles-Crawford should be considered; it is believed that when an equal intensity of light enters the eye near the center of the pupil, it produces a greater photoreceptor response compared with the light entering the eye near the pupillary edge.52 According to this principle, narrowing of the aperture by using a monofocal IOL with an opaque pinhole mask would enhance the depth of focus.28 To this group belong the IC-8 (AcuFocus) and the XtraFocus (Morcher) lenses.

  • IC-8 (AcuFocus Inc.):
  • A single-piece IOL which combines small aperture optics with a monofocal IOL to achieve EDOF (Fig. 8). It is a hydrophobic-acrylic IOL, and the total diameter is 12.50 mm, with a 6.00 mm optic. The optic presents a central 3.23-mm black opaque annular mask composed of polyvinylidene difluoride and carbon nanoparticles, which blocks defocused paracentral light rays, at the center of which lies a 1.36-mm nondiffractive clear circular aperture that allows entry of paraxial light rays giving an EDOF effect (Fig. 9). It is not pupil-dependent.53,54 Clinical studies results have shown that the IC-8 provides good near, intermediate, and distance vision, both after contralateral and after bilateral implantation,54–56 with an extended range of depth of focus particularly evident in photopic conditions.54 Evaluation of visual fields in eyes implanted with an IC-8 IOL using the Zeiss Humphrey 24-2 SITA standard test showed a small but clinically insignificant diffuse reduction in sensitivity with no localized scotomas,57 nonetheless, it should be noted that peripheral visual field is lost (as in any pinhole system). The incidence of photic phenomena has been variably linked to the quantity of light entering the ocular bulb.58 Based on its principle, the IC-8 lens is associated with clinically insignificant amount of dysphotopic phenomena, and with increased patient satisfaction.54,59
  • XtraFocus Pinhole Implant (Morcher):
  • The pinhole device is a black opaque diaphragm with an overall diameter of 14.00 mm and a 1.30-mm central opening with no refractive power (Fig. 10). It is designed to be implanted in the ciliary sulcus of pseudophakic eyes in a piggyback configuration. The haptic is thin (250 mm), rounded, and well-polished to prevent injury to the uveal tissue. The 14-degree angulation prevents iris chafing and pigment dispersion. The 6.00 mm occlusive part of the device has a concave-convex design to prevent contact with the primary IOL located in the capsular bag. The device is made of foldable hydrophobic acrylic which blocks visible light but is transparent to infrared light >750 nm, to permit retinal examination through the opaque material with optical coherence tomography and scanning laser ophthalmoscope.59–61

IC-8 small aperture intraocular lens (IOL) (AcuFocus Inc.).
Small aperture technology allowing only central light rays to focus on the retina providing an extended depth-of-focus.
XtraFocus Pinhole Implant (Morcher).

Small aperture implants have fixed pinhole diameter which does not vary with ambient lighting conditions, thereby limiting the visual acuity in scotopic conditions. A case report published by Agarwel et al61 reported this disadvantage of the design in dim light condition which persisted to the extent of necessitating explantation of the implant. This lens was discontinued due to the difficulties in its centration.

Type 3—MF With Low-Power Near-Vision Addition

MF, refractive and/or diffractive, with low addition for near vision. However, the defocus curve of these lenses masquerades the one of EDOF lenses. For this reason, there was a commercial misinformation regarding the attribution of this type of lenses to the EDOF group while they are really low-power MFs.

  • Lentis Comfort, LS-313 MF15 (Teleon Surgical):
  • This is a rotationally asymmetric MF IOL with +1.50 D near addition (Fig. 11). It is a plate-haptic hydrophilic acrylic IOL with hydrophobic surface properties, rotationally asymmetric, refractive MF IOL, combining an aspheric distance vision zone and a sector-shaped near vision zone with an add power of +1.50 D on the lens plane. It has a 6.00-mm biconvex optic and an overall length of 11.00 mm,62–64 and it is pupil-independent.4 In clinical studies, the Oculentis +1.50 provided excellent distance and intermediate vision, but near vision was not enough for reading small prints. Contrast sensitivity was high, with very low incidences of photic phenomena and a high level of patient satisfaction.65,66 In vitro performance of the lens under polychromatic light demonstrated that additionally to the low add value, the segmented bifocal design gives the lens its EDOF character.66
  • Acunex Vario AN6 V (Teleon Surgical):
  • The Acunex Vario AN6 V lens is a foldable single-piece IOL for EDOF and high-contrast sensitivity with aspherical surface and blue light filter (Fig. 12). The overall IOL diameter is 12.50 mm, with C-loop haptics, and optical zone of 6.00 mm. The addition for intermediate vision is +1.50 D. The Acunex IOL shares the same basic optical design as the Lentis IOL, with a relatively low addition of 1.50 D, however, Acunex is a hydrophobic, whereas the Lentis is a hydrophilic acrylic lens.28,67
  • AT LARA 829 MP (Carl Zeiss Meditec):
  • The AT LARA has a continuous diffractive surface profile from intermediate to distance focal points (Fig. 13). The IOL is made of a hydrophilic acrylate material (25% water content) with hydrophobic surface properties. The overall lens diameter is 11.00 mm with an optic diameter of 6.00 mm. The optical design is diffractive and aspheric. It has an aberration-neutral and CA-correcting optical design.68,69 An optical bench study with polychromatic light demonstrated that the lens is designed so that each wavelength behaves differently but it produces an EDOF profile for polychromatic light.69 The performance of the lens is dependent on pupil size.4 Clinical results confirm good visual acuity for intermediate to far distances, to yield satisfying optical quality, and to result in less dysphotopic phenomena. However, near-distance activities will most likely still require spectacles.70

Lentis Comfort LS-313 MF15. A refractive multifocal with sector-shaped near vision low add.
The Acunex Vario AN6 V.
AT LARA (Carl Zeiss Meditec).

Type 4—Hybrid MF-EDOF: Low Near-Vision Power Addition+HOA Manipulation

Hybrid MF-EDOF with limited near vision power addition+modest manipulation of the negative SA of the lens.

EDOF IOLs aim to give an elongated focus of vision by manipulating the induced SA of the IOL. However, the SA causes a degradation of visual quality and may affect distance visual acuity. To negate this negative effect, some MF lenses incorporate limited amounts of negative SA.71 Type 4 lenses are similar to type 3, although they tend to slightly increase the effect of the near addition through the aberrometric effect. These lenses cause halos and glare, though less than the regular MF IOL.

  • FineVision Triumf POD L GF (PhysIOL):
  • This is a single-piece, hydrophobic-acrylic hybrid MF-EDOF IOL apodized, foldable lens (Fig. 14). The FineVision Triumf design uses the combination of 2 bifocal diffractive gratings elements, one for distance and near and one for distance and intermediate, with additions of +3.50 and +1.75 D for near and intermediate vision, respectively. The height of the 2 bifocal diffractive gratings is adjusted to favor the intermediate focus and to modulate CA, while allowing the creation of a near foci of lesser energy. These gratings have globally higher steps and diffract mainly visible light in the first and second order. The focus for far is not generated by the zeroth order but rather by a combination of light refracted by the monofocal component and the diffraction in the first order. This corrects the CAs for far and intermediate foci and enables a continuous range of focus. The performance of this IOL is dependent on the pupil size. The overall diameter is 11.40 mm, with a biconvex aspheric optical surface in a diameter of 6.00 mm and −0.11 μm SA. The lens has UV and blue filtering. The lens is made of glistening-free material and double C-loop with ridge technology to reduce the risk of stickiness between the haptics and the optic.4,72,73
  • Tecnis Symfony ZXR00 (Johnson & Johnson Vision):
  • The Tecnis Symfony is a C-loop single-piece extended range of vision IOL based on diffractive achromatic technology (Fig. 15). The total diameter of the IOL is 13.00 mm, and the optic zone diameter is 6.00 mm with a refractive index of 1.47. It is an UV-filtering hydrophobic-acrylic material. This lens is available in the range of spherical powers between +5.00 and +34.00 D in 0.50 D increments, with an addition of +1.75 D at the IOL plane.14,74 It consequently incurs a reduced number of diffractive zones (called echelettes by the manufacturer).4
  • The lens has a biconvex wavefront-designed anterior aspheric surface (−0.27 μm) and a posterior achromatic diffractive pattern with an echelette design. Symfony uses 2 complementary enabling technologies: echelette design feature and achromatic technology. The echelette technology is based on a design that forms a step structure whose modification of height, spacing, and profile of the echelette extends the depth of focus. These designs in combination with achromatic technology and negative SA correction improve simulated retinal image quality without compromising depth of field or tolerance to decentration.4,75 The performance of this IOL is dependent of the pupil size.4
  • Clinical studies demonstrate that the extended range of vision of the symphony IOL provides good visual acuity across all distances after cataract surgery, with a minimal level of disturbing photic phenomena and high levels of patient satisfaction.14,74–76
  • Lucidis (Swiss Advanced Vision, SAV-IOL SA):
  • Lucidis is a new type of refractive EDOF hybrid IOL involving a central aspheric element surrounded by an outer refractive ring (Fig. 16). It is a single-piece foldable multizone refractive/aspheric IOL, with a 360-degree square edge design and closed-loop haptics. The lens has a 6.00-mm optical diameter and a total diameter of either 10.80 mm or 12.40 mm, designed for capsular bag implantation. It is available in a power range from +5.00 to +30.00 D in 0.50 D steps with +3.00 D add/EDOF power. The lens material is made from hydrophilic acrylic with a 26% water content.77
  • The central aspheric zone in an area of 1 mm acts as an axicon, so that the emerging light forms a Bessel beam, resulting in a beam of focal fields that allow a continuous vision from intermediate to short distance (Fig. 17). This aspheric geometry does not generate any additional SA to the lens.78 According to the manufacturer, the main benefit of this particular design compared with classical monofocal optics is to provide additional comfort in near and intermediate vision, while still achieving the same optical quality and visual acuity for distance vision. The lens is to be aberration-neutral and minimize the rates of dysphotopsia.77,79 Notwithstanding the benefits, this IOL was found inferior for distant uncorrected visual acuity, compared with results of other EDOF IOLs.79 Nonetheless, clinical studies show that the Lucidis achieves highly satisfactory refractive results and visual outcomes at all distances with low rates of photic phenomena.78,80
  • Supraphob Infocus IOL (Appasamy Associates):
  • This is a proprietary newer-generation refractive EDOF IOL and is really a bifocal refractive lens with an EDOF profile (Fig. 18). The IOL is made of hydrophobic-acrylic yellow chromophore material and has a central zone of 1.20 mm diameter that has a nanodiffractive optics primarily for near and intermediate vision with an additional power of +3.50 D to focus the objects between 33 and 80 cm. Light rays passing through an area 0.30 µ below the edge of this central zone undergo an inward bend eliminating the light scatter, which reduces the chances of glare. Light rays passing between 1.21 mm and 4.75 mm from the center of the optic focus distant objects and provide a clear distance vision. Its anterior surface has a refractive pinhole design. The posterior surface has a 360-degree enhanced square edge design with an aspheric optic. Its overall diameter is 13.00 mm with an optic size of 6.00 mm, and it is independent of pupil diameter of up to 4.75 mm.81 This lens is obviously not real EDOF but rather a bifocal lens which offers a peripheral asphericity to increase the effectiveness for near as a support for the optical power of the lens82 (Fig. 19).
  • In clinical studies the Supraphob EDOF IOL provided good unaided visual acuity for distance, intermediate, and near along with a high quality of vision as assessed by contrast sensitivity, HOAs, and stereoacuity.81,83
  • EDEN (Swiss Advanced Vision, SAV-IOL SA):
  • EDEN is a foldable single-piece, hydrophilic, acrylic, hybrid MF-EDOF lens (Fig. 20). Its aspheric optical center is surrounded by its refractive-diffractive outer surface. The lens is pupil-dependent (Fig. 21). It has a closed-loop design with a total diameter of 10.80 mm or 12.40 mm, and an optic size of 6.00 mm. It is available in a power range from +5.00 to +30.00 D in 0.50 D steps with +3.00 D add/EDOF power.84
  • Harmonis (Swiss Advanced Vision, SAV-IOL SA):
  • Harmonis is a customizable EDOF IOL. It is a foldable single-piece hydrophilic acrylic (26% water content) with an aspheric optical center surrounded by a refractive-diffractive outer surface (Fig. 22). The total diameter is 10.80 or 12.40 mm, with an optic size of 6.00 mm. It is available in a power range from +5.00 to +30.00 D in 0.50 D steps with +2.50 to +3.50 D add (0.25 D steps) and with an EDOF effect of +1.00 to +2.00 D (0.50 D increments).85
  • Synergy ZFR00 (Johnson & Johnson Vision):
  • Synergy ZFR00 is a bifocal combined with EDOF technology for intermediate vision with potentially better visual continuity than trifocal lenses (Fig. 23). It is made of a hydrophobic-acrylic material. The lens features a wavefront-designed aspheric surface and keeps the CAs corrections offered on the Symfony. Its posterior surface is diffractive with 15 rings.86 The lens performance is independent of pupil size.4 The distinct added power of the ZFR00 IOL is kept as proprietary information, and the photic phenomena are reportedly reduced using Optiblue material that passes blue light and blocks violet light.87 In clinical studies the ZFR00 IOL provides good far, intermediate, and near vision, under both photopic and mesopic conditions, resulting in a high level of patient satisfaction,87–89 with limited deterioration under mesopic conditions, which is perceived as a satisfactory outcome by patients if proper patient selection is performed.89

FineVision Triumf POD L GF (PhysIOL). A hybrid multifocal—extended depth-of-focus intraocular lens (MF-EDOF IOL).
The Tecnis Symfony (Johnson & Johnson). Hybrid multifocal diffractive/extended depth-of-focus intraocular lens (EDOF IOL).
Lucidis (Swiss Advanced Vision, SAV-IOL SA).
An aspheric surface in the center of the lens generates a pseudo-nondiffractive beam (PNDB) of light, enabling to extend the depth of focus (EDOF).
The SupraPhob Infocus IOL. Using a central small refractive element to increase depth of focus for near and progressive refractive aspheric elements toward the periphery for intermediate and distance vision.
Supraphob Infocus intraocular lens defocus curve, demonstrating the extended depth of focus.
The EDEN lens. A multizone aspheric-diffractive-refractive hybrid multifocal—extended depth-of-focus (MF-EDOF) lens.
Light distribution as a function of pupil diameter with the EDEN lens.
Harmonis (Swiss Advanced Vision, SAV-IOL SA).
Synergy ZFR00 (Johnson & Johnson Vision). A diffractive bifocal combined with extended depth-of-focus (EDOF) technology.

Type 5—Modified Central Optical Profile Lenses

Lenses characterized by a variation in the geometry of their central optical area. These IOLs cause either a change in the power of the lens from the center to periphery, which increases the central power of the lens or an elongation of the focus by a wavefront modulation effect. Their optical principles have not yet been well explained by the creators of these lenses. They lack dysphotopsia and produce good intermediate and for some of them, acceptable near vision.

  • EyHance ICB00 Tecnis lens (Johnson & Johnson Vision):
  • EyHance IOL is merchandized as enhanced monofocal IOL though it offers a smooth and continuous progression of its power from periphery to the center, with no demarcation line (Fig. 24). It aims to present the distance performance and minimum photic effects of the monofocal (ZCB00) while compensating for SAs in the cornea and providing intermediate vision at 66 cm.90 It is a single-piece, hydrophobic-acrylic IOL with a 360-degree posterior square edge and a tiny central plateau and thus a local change in power is applied to EyHance IOL to enable a local refractive change, whereas the basic anterior curvature is aberration correcting with negative primary SA.13,91 Clinically it leads to an improvement in intermediate-distance vision when compared with monofocal IOLs. Regarding defocus, measurements indicate that the TECNIS EyHance IOL has a larger “landing zone” than the TECNIS Monofocal IOL and provides excellent (0.0 logMar) distance vision.90 The lens is pupil-dependent.4 No information is given about modified SA by the manufacturer.92 In a laboratory investigation of visual quality metrics and halo size by Auffarth et al,93 it was demonstrated that the mono-EDOF models had a clear advantage over the standard monofocal lens by expanded imaging capability beyond −0.50 D and that the ICB00’s halo profile was similar to that of the ZCB00, indicating their low potential to induce photic phenomena.
  • AE2UV (Eyebright Medical Technology Inc.), distributed in Europe under the tradename ZOE (Ophthalmo Pro GmbH):
  • The AE2UV/ZOE features an aspheric design to lower the primary SA of the cornea by −0.20 μm at 6.00 mm. A high-order aspheric surface enhances intermediate vision with increased SA aberration in the IOL center that gradually decreases toward the periphery. A smooth and continuous higher order aspheric surface aims to minimize photic phenomena that may result from abrupt profile changes, such as observed in diffractive IOLs (Fig. 25).
  • This IOL is a single-piece hydrophobic-acrylic lens with a refractive index of 1.47. Available in power range from +5.00 to +36.00 D in 0.50 D steps. The total diameter of the lens is 13.00 mm with 6.00 mm optic zone.93,94
  • The AE2UV/ZOE model has the potential to extend the patient’s intermediate vision beyond the range of a standard monofocal lens, with low potential of this IOL to induce photic phenomena.93 Given that this IOL is also still relatively new to clinicians, we were not able to identify any peer-reviewed publication on the in vivo or in vitro functioning of the AE2UV/ZOE as well.
  • Synthesis PLUS (Cutting Edgence):
  • The Synthesis PLUS design is based on a continuous area with an EDOF central zone, a patented transition zone, and monofocal optical periphery, generating a combination of primary and secondary SAs of opposite signs promoting an increase of the depth of field (Fig. 26). The theoretical aim of this is to deliver continuous high-contrast vision from distance to intermediate vision, while maintaining a functional level of near vision and preserving the ocular optical quality within an acceptable range to avoid the induction of light disturbances, such as halos, glare, or starbursts.
  • The Synthesis PLUS IOL is a single-piece EDOF IOL with a 6.00-mm aspheric optic, and a variable overall diameter depending on its power (11.0 mm: 0–15.00 D, 10.70 mm: 15.25–22.00 D, and 10.50 mm: 22.25–32.00 D). It has a 4-point fixation haptics and a continuous 360-degree posterior square optic edge, with a shift aim of promoting capsular bag adhesion (angulation 0-degree). It is made of a hydrophilic acrylic material with a refractive index of 1.459.
  • The clinical performance in pilot studies suggests an enlargement of the depth of focus, as the measurements of the defocus curve obtained show relatively functional levels of near and intermediate visual acuity while maintaining good levels of distance vision but might require spectacles for small print at a near distance or might be enhanced using a micro-monovision or bilateral residual myopic approach.95,96
  • Acrysof IQ Vivity DFT015 (Alcon):
  • Vivity is a nondiffractive EDOF IOL with Alcon’s proprietary nondiffractive X-WAVE technology which stretches and shifts light without splitting it.97,98 A central plateau, similar to the one in the EyHance IOL but more pronounced small plateau of about 1 µm is used by Alcon’s X-Wave Technology (Fig. 27) to stretch the wavefront, combined with a discrete change in radial curvature in the central area of about 2 mm to produce a wavefront shift.99,100 The aspheric design of the Vivity corrects −0.20 µm of primary SA. According to the manufacturer, the Vivity has 2 transition elements in the central 2.20 mm range. The first transition element stretches the wavefront, creating a continuous focus area. The light is stretched in both directions, that is, in the myopic and hyperopic directions. The light in the hyperopic direction is located behind the retina and would not be usable. Therefore, the second transition element moves the wavefront forward, shifting the light from the hyperopic direction to the myopic direction so that the entire light energy is used. The Vivity IOL generates the extended depth of field by means of the aspherical front lens surface and a spherical rear surface.100
  • The lens optic is biconvex, aspheric, wavefront shape, made of a hydrophobic acrylate/methacrylate copolymer with UV and blue light filter material.99 The lens is pupil-independent.4 The index of refraction is 1.55. The optic diameter is 6.00 mm with an overall length of 13.00 mm, with a classic C-loop design. It is available in Europe at spherical power range from +10.00 to +30.00 D.99
  • Though EDOF IOLs are supposed to be less sensitive to optical quality degradation caused by IOL decentration compared with MF IOLs, the small central optical zone of the Vivity IOL seems to make the lens more susceptible to decentration and play an important role in achieving satisfactory intermediate and near visual acuity. A case report recently published by our group101 describes a patient with poor visual outcomes for intermediate and near vision due to poor centration of the central 2.2 mm optical zone of the Vivity IOL, in which IOL exchange solved the visual outcomes. In clinical trials, the lens was shown to deliver monofocal-quality distance vision with excellent intermediate and functional near vision, while maintaining a monofocal-like visual disturbance profile.97 In a prospective study of early real-world experience, Italian researchers confirmed that the lens provided excellent distance and intermediate, while patients needed some spectacle correction at 30 cm.98 The most complained postoperative visual discomfort were halos and glares, with that it was included in a score range of high satisfaction and tolerability of this IOL98 and the dysphotopsia profile is significantly better in the Vivity lens when compared with MFs.102 In a study performed by our research group, evaluating the quality of the retinal optical image following implantation of the Vivity EDOF IOL and compared with a monofocal and a trifocal IOL, it was found that although trifocal IOLs provided significantly better retinal image quality, this IOL also demonstrated to be the most sensitive to residual refractive errors. Both Vivity and monofocal IOLs showed a comparable retinal image quality.103
  • LuxSmart (Bausch & Lomb):
  • The LuxSmart is a nondiffractive, aspheric hydrophobic single-piece acrylic IOL (Fig. 28) with a 6.00-mm diameter optical zone, 4 fixation haptics, and 11.00 mm diameter in total. It is available with and without a violet filter.
  • The lens design of this EDOF IOL is based on the so-called pure refractive optics principle. There is an EDOF center followed by a transition zone and a monofocal aberration-neutral periphery.100 According to the manufacturer, the LuxSmart uses a combination of fourth and sixth orders of SA of opposite sign, The fourth-order SA (Z4,0) theoretically will increase the depth of focus of about 0.88 D, the sixth-order SA (Z6,0) of about 2.00 D, combined of the opposite sign leading to at least 1.50 D depth of focus.92
  • The preliminary clinical results show that new LuxSmart EDOF IOL achieved higher performance for uncorrected intermediate and near vision compared with a conventional monofocal IOL, without increasing the risk of photic phenomena.104
  • In a prospective study, the LuxSmart provided comparably high uncorrected distance visual acuity and significantly higher distance-corrected intermediate visual acuity than the monofocal lenses, with very limited optical phenomena side effects.105
  • RayOne EMV (Rayner Intraocular Lenses Limited):
  • RayOne EMV lens is offered for blended vision as enhanced monovision IOL (Fig. 29) where a plano target is maintained in the dominant eye, and a power-offset is applied in the nondominant eye. According to the manufacturer, a 1.00 D offset offers a 2.25-D depth-of-focus extension in binocular vision.93 For bilateral emmetropia, it allows for better intermediate vision than standard monovision lenses, providing ∼1.25 D of extended visual range.106

EyHance ICB00 Tecnis lens (Johnson & Johnson Vision)
ZOE (Ophthalmo Pro GmbH).
Synthesis PLUS. EDOF indicates extended depth-of-focus.
Acrysof IQ Vivity DFT015 (Alcon).
The LuxSmart (Bausch & Lomb).
RayOne EMV.

RayOne EMV uses an increased positive SA to enhance the depth of focus, while the lens outer periphery behaves aberration-neutral and is designed to reduce longitudinal SA. Manufacturer’s modulation of HOA in the RayOne EMV is due to very discrete changes in local power in the central area of the lens.92,106

The RayOne EMV overall diameter is 12.50 mm, and the optical diameter is 6.00 mm. It is made of (26%) hydrophilic acrylic material with a refractive index of 1.46 at 35 degrees.92,93 It is less dependent on variable pupil width, decentration, and tilt.107

Given that the IOL is still relatively new to clinicians, we were not able to identify any peer-reviewed publication on the clinical performance of the RayOne EMV.93


Over the past decades, cataract surgery has evolved gradually from a therapeutic vision restoration procedure to a refractive procedure, improving the patient’s quality of life. There is evidence that independence from spectacles improves quality of life.33 In the search for the privilege of independence from spectacles at all distances offered by lens surgery, significant developments in IOLs have emerged and new presbyopia-correcting IOL designs have rapidly developed using different refractive principles.

MF lenses were the first to arrive, either with diffractive or refractive technology, all of which allow the patients to achieve a fuller visual range and greater spectacle independence than monofocal IOLs. The technology of MF IOLs has improved in recent years, and the latest MF models provide better results than previous models. MF IOL implantation results in high levels of uncorrected distance visual acuity. A meta-analysis of peer-reviewed studies found a mean monocular and binocular outcome very close to 0.0 logMAR (20/20).108 The differences in near-vision assessment techniques increase the variability of the uncorrected near visual acuity outcomes between studies. A meta-analysis of 20 studies found a mean uncorrected near visual acuity of 0.141 logMAR following MF IOL implantation,109 and recent studies have reported similar or slightly better outcomes for the latest generation of MF IOLs.1,62 However, these lenses hold certain drawback. The main challenge for MF lenses is that they use a nonphysiological optical method to improve near vision. MF lenses, by definition, separate light into different foci, and this causes a dispersion of the energy of the light entering the eye. This results in a change in the physiology of vision as the light follows a different focal performance at the level of the visual axis and, consecutively, at the level of the retina. It is necessary to activate a process of neuroadaptation, the capability of the brain to adapt to changes, to adjust the neurophysiology of the changes that are induced in the quality of the retinal image by the dispersion of light. Moreover, the overlapping of different foci is neither normal nor physiological. Common problems with MF lenses are blurred vision and photic phenomena associated with residual ametropia, posterior capsule opacification, large pupil size, wavefront anomalies, dry eye, and lens decentration. The main reasons for these are residual refractive error, lens dislocation, lens opacification, and failure to neuroadapt derived from MF decompensation of light.3

Recently, out of necessity to eliminate the problems derived from MF decompensation of light, the EDOF lenses have been developed. These seek to occupy the intermediate space between the monofocal lens, with which dysphotopsia is practically absent but there is no independence from spectacles, and the MF lens with which independence from spectacles might have a symptomatic cost for the patient.28,82

EDOF lenses create a continuous change in focus from far and near without the overlapping of images that constitute MFs. To achieve that, certain amounts of ocular aberrations are increased on purpose to create the minimal blur necessary to see different distances. In contrast to the recent development of modern monofocal IOLs in which the compensation of the aberrations of the eye-targeted zero aberrations, the optics of the IOL are transformed with the induction of a certain amount of aberrations with the benefit of near-vision performance. The resulting cost of this is quality of vision, which is degraded.82

Any IOL should ideally minimize ocular wavefront aberrations and optimize the retinal image quality,110 to prevent the impact that a low retinal image can have in visual quality and contrast sensitivity, as a decreased quality of image with blurred vision limits the neuroadaptation process. Neuroadaptation failure is mainly characterized by decreased quality of vision, sometimes with no correlation with the objective parameters of optical quality and no solid underlying reason such as posterior capsule opacification, dry eye, or retinal disease. The reduction in this far distance quality of vision is generally due to sensations of blurred vision, dysphotopsia, or photic phenomena. Therefore, it is of primary concern how our brain reacts to a new input, such as what follows after implanting MF or EDOF lenses, and it is in good part related to the far distance retinal image quality, as a bad retinal image quality is inevitably a compromise and a limitation for the neuroadaptation process; however, other factors such as photic phenomena or the type of defocus curve are also considered to play a role in the tolerance to such atypical optics.111

When considering the impact of IOLs on optical aberrations, one must consider how much light energy is intentionally and unintentionally directed of axis, especially when considering EDOF or MF, both diffractive and refractive, IOLs. In a monofocal IOL, all light energy focuses on axis in the plane of the retina, therefore, a good retinal image quality is obtained. In the case of aspheric EDOF lenses that increase depth of focus through SA, retinal optical quality in the far focus will inevitably be compromised, since the goal is to achieve a beneficial compromise between the gain in depth of focus and the loss in image quality.35,43 In case of a rotationally asymmetric refractive MF lens, its vertical asymmetric optical geometry provides 2 distant foci for far and near vision by the presence of a calculated magnitude intraocular primary coma.112,113 Although some amounts of vertical coma have a positive effect on near visual acuity because of the enhanced depth of focus, high values of this aberration could limit the eye’s optical quality.114 Our group reported a comprehensive evaluation of the postoperative optical effect of different types of premium pseudophakic IOLs including MF refractive and diffractive IOLs, EDOF Mini Well IOL, accommodating designs, and monofocal spherical and aspheric IOLs44 which demonstrated a drastic significant reduction in the retinal image quality in the Mini Well lens, compared with a monofocal spherical IOL. Also, a trend was found toward a larger magnitude of HOA root mean square value in the far distance image in eyes implanted with a +3.00 D posterior sector-shaped near-vision zone (Mplus MF30). These findings suggest that the use of a larger add for the rotationally asymmetric IOL limits optical quality, with an effect on retinal image quality. The far distance retinal image quality in patients implanted with the Tecnis Eyhance, which aims to enhance the image quality at intermediate distances without compromising distance vision, based on a continuous refractive optical surface design, was relatively good.

How the different IOL optics influence the quality of retinal image could influence IOL selection for the correction of pseudophakic presbyopia and guide surgeons in the evaluation and selection of the IOL to be implanted.

We believe that an IOL should be named an EDOF lens when it does not have either refractive or diffractive added multifocality.82 We define EDOF lenses as being those that use diverse optical manipulation to increase depth of focus and improve intermediate vision and, to certain extant, near vision, showing minimal photic affectations of the type that are typical to MF lenses. The specific mechanism at play is the manipulation of SA or other radial orders, creating special profiles of the lens. True EDOF lenses are only those based on the change in the patient’s aberrometric profile; others are simply low-power MF that because of their low addition, are not likely to cause discomfort and dysphotopsia to the patient.

The final practical definition would be given by the clinical defocus curve, in which the classic focal peaks would not be observed, but rather an extension of the focal plane from far to the closest distances. In practice, this effect on the defocus curve can be achieved in a number of ways. Based on this criterion, we classified EDOF lenses into 5 types, as detailed in this review article, which allow them to be typified and thus allow the surgeon who chooses them to understand the characteristics of each lens.33

The AAO consensus statement for EDOF IOLs43 has provided a benchmark and recommendations for classifying an implant as an EDOF IOL and evaluating the performance of each type of EDOF IOL technology. Nevertheless, there is confusion in the terminology and some of the so-called EDOF lenses available today are really MF lenses with low near add power, in which part of the rest of the power has been withdrawn to avoid the overlapping of images and the consequent halos and glare.

Multifocality and EDOF characteristics are not exclusive of each other. A bifocal IOL may exhibit EDOF characteristics, likewise with an aspheric monofocal IOL or a diffractive or refractive trifocal IOL.115

The development of presbyopia-correcting IOL is challenging as accommodation is a dynamic process, and the above-mentioned designs do not directly address the mechanism of accommodation. Also, it is important to note that the EDOF technology cannot provide >1.50 D range of focus.

This is where another player enters the game. Accommodative lenses attempt to adjust the focus for different distances by way of imitating the mechanism of natural accommodation, with various theoretical assumption, however, much more development is required to improve its clinical outcomes,71 in light of the issues encountered with these lenses including lens dislocation,47,48 capsular bag contraction syndrome, pseudoaccommodation, as well as a high rate of posterior capsular opacification.116

At present, there is a wide range of presbyopia-correcting IOLs in the market. Therefore, a careful and complete examination of the patient along with a thorough discussion with the patient of the most appropriate option based on the risk benefits balanced with patients’ lifestyle, expectations, and visual requirements would be recommended.

In conclusion, with the rapid innovation in the field of IOL materials and design, the future looks promising. In the future, refractive surgery may be guided by artificial intelligence in which multiple diagnostic tools will receive information about the eye and will guide the surgeon regarding the lens most suitable to a specific patient.108 A potential number of devices are on the market and awaiting publication, including spectacle-mounted devices that may collect preoperative data regarding the patients’ true distance, luminance, and usage data.

In parallel, future research will continue toward finding a balance between dysphotopsia, EDOF, and quality of vision.

Probably at this moment EDOF lenses are covering a transitional moment when we are going from optical multifocality to the real development of lenses capable to restore accommodation. Accommodative IOLs will be with no doubt found in the future in models and designs that are more effective and better than the past. Once this happens, the Holy Grail of the restoration of the function of the crystalline lens degraded with the development of cataract is fully accomplished.


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extended depth of focus; hybrid lenses; intraocular lenses; presbyopia; retinal quality image

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