WRITER Dr Daniel Athavale

Cataract surgery has undergone a remarkable transformation over the past decade. Advances in phacoemulsification technology and the expanding range of intraocular lenses (IOLs) have fundamentally changed the way surgeons approach visual rehabilitation after cataract extraction.1
But, as Dr Daniel Athavale writes, for ophthalmologists practising in rural and regional populations, there are additional patient lifestyle and visual demands that may need to be taken into account.

Two decades ago, the approach to IOL selection was relatively straight forward. Most patients received a monofocal lens targeting emmetropia in both eyes, or occasionally, monovision with mild myopia in the non-dominant eye.1 While this allowed functional distance vision, most patients accepted the trade-off that reading glasses would usually be required for near and intermediate tasks.

Today, patient expectations are very different. The modern visual environment is dominated by smartphones, tablets, laptops, and digital displays. Even cars now incorporate large interactive screens that require frequent engagement. In this setting, reaching for glasses to monitor the dashboard or adjust the air-conditioning while driving can feel frustrating and inconvenient. As a result, many patients now present for cataract surgery with a strong desire for greater spectacle independence.2

Premium IOL technologies – including enhanced monofocal lenses, extended depth of focus (EDOF) lenses, and trifocal designs – have emerged to address these expectations.3,4 While these lenses were initially adopted in metropolitan practices, demand is increasingly being Seen in regional settings. After practising almost exclusively in regional communities for the past five years, I have seen firsthand how patient expectations have evolved, along with my own approach to matching IOL technology to individual patient needs.

LIFESTYLE DIFFERENCES IN REGIONAL PRACTICE

One of the most noticeable differences between metropolitan and regional patients relates to lifestyle – particularly driving.

Patients in regional areas are often heavily reliant on driving to maintain independence. Public transport options are limited, distances are greater, and many patients regularly drive on poorly illuminated rural roads.5 Night driving is therefore not simply optional; for many patients it is essential.

This becomes particularly relevant when considering trifocal IOLs. These lenses, which rely on diffractive optics, can produce dysphotopsias such as haloes and glare, and may reduce contrast sensitivity.6 While these visual phenomena are often well tolerated in urban environments with good lighting, they can be more problematic on dark rural roads.

For this reason, careful patient selection becomes even more important.7 Inappropriately selected patients may experience significant nighttime visual disturbances, which can affect both comfort and safety when driving.

OPHTHALMIC HEALTH CONSIDERATIONS

Another important consideration in regional practice is the prevalence of certain ocular conditions.

Patients living in regional and rural Australia often have higher rates of conditions such as pterygium and diabetic retinopathy.5 Both conditions can influence the suitability of premium IOL implantation, particularly trifocal lenses.

Pterygium provides a good example. In addition to patients with active pterygium at

the time of cataract surgery, many regional patients have previously undergone pterygium excision. Residual corneal scarring, irregular astigmatism, or focal thinning may affect visual quality and therefore influence IOL selection.8

Similarly, diabetic retinopathy – particularly when associated with macular involvement – may limit the visual benefit of certain premium lenses.9 These conditions do not necessarily exclude all premium IOL options, but they often shift the discussion toward technologies that preserve contrast sensitivity and produce fewer photic phenomena, such as non-diffractive EDOF lenses.4

IMPORTANCE OF PATIENT SELECTION

Ultimately, successful use of premium IOLs relies on careful patient selection and matching IOL technology to the needs of the patient.7

Clinical questionnaires provide a useful starting point, but they should never replace detailed discussion and clinical judgement. There is no single ‘perfect’ IOL for every patient. Instead, surgeons need a broad range of technologies available – a ‘surgical tool kit’ approach – so that the most appropriate lens can be selected for each individual patient.1,7

I regularly use the Medicontur Bi-Flex IOL platform. Medicontur is an IOL manufacturer based in Hungary. The Bi-Flex platform comes in a wide range of models and powers, and in a stable design that I find accommodates a wide range of patient needs. The platform includes monofocal IOLs with a power range covering -10.0 to +55.0D, which is sometimes very handy. Toric IOLs are available in extreme powers up to 24.0D of cyl, which is not a common offering in most brands of commercially available IOLs. Refractive EDOF IOLs (Elon) are also available, allowing for functional intermediate and some near vision with minimal photic side effects. The ultimate range of vision IOL – the diffractive Liberty – is useful for patients seeking complete spectacle independence with reduced haloes and glare phenomena.

Medicontur also provides the 1stQ AddOn secondary supplementary sulcus IOL, which is like a ‘get out of jail free card’, as it allows for reversible correction of presbyopia, trifocal upgrades, and refractive fine-tuning.

The clinical examination plays an important role in identifying anatomical indications for each of these IOLs. Slit-lamp examination, optical biometry, corneal topography, and optical coherence tomography can provide valuable insight into whether the eye itself is suitable for premium IOL implantation.1

However, the anatomical assessment is often the easiest part of the consultation. The greater challenge lies in understanding the patient.

UNDERSTANDING PATIENT GOALS AND EXPECTATIONS

Determining a patient’s goals, lifestyle, and expectations may involve more time than the technical aspects of the examination.

Many regional patients are relatively comfortable wearing glasses for specific tasks and may not feel strongly motivated to pursue full spectacle independence. Other patients, however, may have spent much of their lives without glasses or contact lenses and feel strongly about maintaining that independence following surgery.

Patients considering trifocal IOLs must also be willing to tolerate a period of neuroadaptation. In the first few months after surgery, haloes and glare are common as the brain adjusts to the optical system of the lens.10 Most patients adapt well over time, but a small group may struggle with these visual phenomena.

Interestingly, patients who have previously adapted well to multifocal spectacles often tolerate trifocal IOLs more successfully.10 This observation can sometimes provide useful insight when discussing options with patients.

Medicontur Liberty Trifocal lenses have low rates of glare and haloes due to only having seven diffractive rings in the lens (other manufacturers of trifocal IOLs may have 15 or more diffractive rings). This stable lens design, coupled with the low number of diffractive rings, allows me to achieve excellent visual outcomes and facilitates neuroadaptation.

I also have the option to use a 1stQ AddOn Trifocal (same trifocal technology as Liberty) in the ciliary sulcus; either in a planned dual lens procedure or as a trifocal upgrade in a pseudophakic patient who does not want to lose the opportunity for spectacle independence, but may not meet all the important clinical and personality criteria for an ‘in the bag’ trifocal IOL.

For patients who are unsuitable for trifocal IOLs, advancements with refractive EDOF IOL designs enable a good level of spectacle independence with minimal or no photic side effects, such as haloes and glare.4 I have found that the Medicontur Elon refractive EDOF lenses provide very good refractive outcomes with good intermediate and some functional near vision in my patients. I inform all who receive an EDOF lens that they are likely to need to wear reading glasses for fine print at near. Although I can also offer mini-monovision with EDOF lenses, I am careful with this approach as it may compromise stereopsis.

BALANCING BENEFITS AND TRADE-OFFS

Studies suggest that spectacle independence following bilateral trifocal IOL implantation can exceed 90%.3 However, these benefits always come with trade-offs.

Haloes, glare, and starbursts are well recognised side effects of diffractive IOL designs.6 While these symptoms typically improve as neuroadaptation occurs, a small proportion of patients find them difficult to tolerate.10

Figure 3. Liberty Trifocal toric IOL.

Figure 4. Point spread function map of the Liberty EPS 2.0

Careful counselling and patient selection remain the most effective ways to minimise dissatisfaction.7

Expert guidance from organisations, such as the European Society of Cataract and Refractive Surgeons, suggests that ideal candidates for trifocal IOLs generally share several characteristics: healthy eyes without significant corneal or retinal disease, realistic expectations, and a strong motivation for spectacle independence.7

When these factors align – along with careful assessment of lifestyle and visual needs – premium IOL technology can deliver excellent outcomes and high levels of patient satisfaction.

In regional practice, the key lies in understanding that while patient expectations may increasingly mirror those of metropolitan populations, their lifestyles and visual demands can be quite different. Recognising these differences allows surgeons to tailor IOL selection more effectively, ensuring that technology serves the patient, rather than the other way around.

This article was sponsored by SurgiVision, the exclusive distributor of Medicontur and 1stQ in Australia and New Zealand.

Dr Daniel D Athavale MBBS (Syd) MPH (Syd) FRANZCO is a comprehensive ophthalmologist, with special interests in cataract, glaucoma and medical retina. He has sub-specialty Fellowship training in complex cataract and glaucoma filtration surgery, as well as minimally invasive glaucoma surgery (MIGS). Dr Athavale practises at Hunter Eye Surgeons in the Newcastle and Hunter Valley region and also works at St. Leonards Eye Centre in Sydney.

References available at mivision.com.au.