In this episode of Interventional Mindset, Amir Marvasti, MD, a cataract, cornea, and refractive surgeon in Orange County, California, discusses strategies for selecting an advanced intraocular lens (IOL), emphasizing the importance of shifting the framework from “What’s the best lens?” to “Which lens best aligns optical design, patient anatomy, and visual priorities for this particular patient?”
IOL decision-making strategies
According to Dr. Marvasti, optimal IOL selection requires a thorough understanding of:
- Lens optical design: Understanding how extended-depth-of-focus (EDOF), multifocal, and light‑adjustable intraocular lenses (LAL) perform.
- Patient ocular health: Identifying comorbidities that may limit vision.
- Patient expectations and lifestyle: Clarifying what “better vision” means, daily visual tasks, and tolerance for trade‑offs.
Dr. Marvasti stresses that no test, questionnaire, premium IOL, or next‑generation laser or diagnostic device can replace a direct conversation with the patient. Understanding their visual demands, night‑vision sensitivity, and the importance they place on spectacle independence is critical to selecting the right lens.
He acknowledges the inherent uncertainty in IOL selection for both surgeons and patients. Dr. Marvasti emphasizes the importance of developing comfort with this responsibility and avoiding the tendency to default to one or two preferred lens categories.
He notes that maintaining a broad IOL portfolio demonstrates a surgeon’s willingness to take the time to listen, understand, and personalize their patients' vision outcomes.
Extended-depth-of-focus IOLs
Extended-depth-of-focus (EDOF) lenses form a single, extended focal zone rather than multiple separate focal points.1 Dr. Marvasti explains that EDOF lenses rarely cause dysphotopsias (glare, halos, or starbursts), with rates comparable to those seen with monofocal IOLs.2
They do not provide consistently clear near vision, however. The main source of dissatisfaction in Dr. Marvasti’s experience is unmet expectations for reading. For this reason, he emphasizes pre-operative counseling about the likely need for reading glasses.
EDOF IOL pearls
EDOF designs are more forgiving of small refractive errors, mild residual astigmatism, and minor ocular disease than diffractive multifocals. However, the final outcome may still be affected by conditions such as maculopathy and optic neuropathy.3,4,5
Ideal candidates for EDOF IOLs
Risk-averse patients who prioritize distance and intermediate tasks (e.g., driving, computer work), night vision, and will tolerate readers.
Multifocal/diffractive lenses
Multifocal lenses enhance near vision by splitting incoming light into multiple focal points.6 In Dr. Marvasti’s experience, multifocal IOLs provide the most consistent option for full‑range vision (distance, intermediate, near) and a high degree of spectacle independence. However, because of how light is dispersed, the lenses can induce dysphotopsia.
Multifocal IOL pearls
If full‑range spectacle independence is the primary goal, multifocals offer the strongest option, but patients may experience nighttime glare, halos, and starbursts. Most patients adapt over time, though some remain symptomatic.
Because multifocals are less forgiving of residual refractive error and mild ocular surface disease or maculopathy, he stresses the need to be prepared to treat residual refractive error (e.g., laser enhancement or IOL exchange) and to screen carefully.7
Ideal candidates for multifocal IOLs
Individuals who are strongly motivated to avoid glasses and clearly understand the optical tradeoffs, such as having glare and halos at night. Patients who are highly risk‑averse or unwilling to compromise night vision are, in his view, poor candidates. He specifically flags frequent night drivers (e.g., truck drivers) as being less suitable.
Light-adjustable lenses
Light‑adjustable lenses (LALs) allow fine-tuning of lens power once the eye has healed and the prescription has stabilized. This allows vision outcomes to be customized and optimized.8
Dr. Marvasti recommends LALs when prioritizing refractive accuracy and adjustability over convenience, as they require longer post-operative care.
LAL pearls
Adjustable lenses correct lower‑order aberrations effectively but not higher‑order aberrations.9 Dr. Marvasti advises avoiding them in eyes with severe irregularity, such as advanced Salzmann nodular degeneration, significant map‑dot‑fingerprint dystrophy, limbal stem cell deficiency, or severe ocular surface disease.
Ideal candidates for LALs
Adjustable lenses are particularly useful for:
- Patients with extreme myopia/hyperopia or prior corneal refractive surgery, especially with multiple enhancements, where formulas are less reliable.
- Patients unsure of their final refractive goal (e.g., uncertain about monovision), allowing post-operative refinement based on their lived experience of different targets.
Dr. Marvasti's advice: If you would not implant a toric IOL because of corneal quality, you should avoid an adjustable lens in that eye.
Clinical application and patient selection
During consultation, Dr. Marvasti describes constructing a profile that includes optical tolerance, visual preferences, task demands, comorbidities, willingness to participate in post-operative care, and the importance of spectacle independence, then narrowing choices to two or three lens strategies before recommending one.
He concludes that patient selection involves matching each patient to the appropriate IOL category. It is the central determinant of success and, in his words, remains the most powerful and often underutilized tool, even as lens and diagnostic technologies continue to advance.
Key takeaways
- Successful IOL selection depends on aligning lens optics, ocular biology, and patient psychology through direct conversation.
- EDOF lenses generally provide good distance and intermediate vision with monofocal‑like night vision, but often require reading glasses.2 This expectation must be set clearly.
- Multifocal lenses provide the most consistent option for full‑range vision and broad spectacle independence, but do not guarantee it.7 Patient conversations are critical for selecting appropriate candidates.
- Adjustable lenses improve refractive accuracy in extreme refractive errors and post‑refractive eyes, and allow post-operative fine‑tuning for patients uncertain about their target.8,9
- Use a thoughtfully varied mix of lens technologies rather than relying on one or two categories for most cases.
