In this episode of Interventional Mindset, Tanner Ferguson, MD, discusses how his practice uses a multi-layered diagnostic workup and virtual reality simulation to guide patients toward the right intraocular lens (IOL) at the time of cataract surgery.
Dr. Ferguson is a cornea, glaucoma, cataract, and refractive surgeon at Vance Thompson Vision in Sioux Falls, South Dakota, and Sioux City, Nebraska.
IOL selection fast facts
- Corneal topography, an OPD-Scan for higher-order aberration data, and optical biometry each generate an independent keratometry reading, and pairing multiple devices improves toric IOL accuracy.
- A 2026 comparison of optical biometry and Scheimpflug topography found a significantly lower post-operative astigmatism prediction error with optical biometry (0.53D vs. 0.78D) in eyes with central irregular astigmatism.1
- Concomitant macular conditions are common amongst cataract surgery patients, with some studies reporting conditions such as AMD and ERM are present in up to 40% of cataract patients.2
- Diffractive multifocal IOLs are relatively contraindicated in ERM eyes: even a non-foveal-involving membrane can measurably reduce contrast sensitivity without necessarily changing visual acuity.3
- The Light Adjustable Lens (LAL, RxSight) does not split light the way a diffractive multifocal does, so it does not worsen outcomes in the presence of macular pathology. A study published earlier this year reported favorable results of the LAL in eyes with macular pathology.4
- In a randomized comparison at two private practice sites, patients who previewed lens options through a virtual reality headset chose an advanced technology IOL at nearly double the rate of patients who received standard verbal counseling alone.5
Matching diagnostics to candidacy
Every cataract evaluation at Dr. Ferguson's practice runs through a standardized battery before any lens conversation happens: Scheimpflug tomography, an OPD-Scan for a second topography source, and optical biometry for a third keratometry reading, alongside OCT of the retinal nerve fiber layer and macula to screen for glaucoma and macular disease.1
“When they're undergoing cataract surgery, they're very much choosing a lens option that's going to dictate how they use their eyes from here on out.”
A brief intake questionnaire on spectacle-independence goals tells Dr. Ferguson, before he enters the room, whether a patient is motivated toward a presbyopia-correcting lens. That upfront screening catches patients who need a different conversation. A patient who wants to reduce glasses dependence but has a mild ERM on OCT is not a multifocal candidate.3 That does not put the patient's goals off the table, though.
In this instance, Dr. Ferguson explains to the individual: "I understand you're motivated to not wear glasses or reduce your dependency on glasses after surgery. Unfortunately, you're not a great candidate for what's called a multifocal lens because of that wrinkling on the surface of your retina, but you would be a good candidate for another advanced technology lens known as a Light Adjustable Lens."
The LAL's tolerance of macular pathology makes that redirection possible: because the lens is monofocal in design rather than diffractive, it avoids the light-splitting mechanism that degrades contrast sensitivity in eyes with retinal surface disease.6
Dr. Ferguson notes he will also consider the new PureSee (Johnson & Johnson Vision) extended-depth-of-focus (EDOF) IOL in these situations. That distinction keeps an ERM patient in the premium-lens conversation instead of defaulting them to a standard monofocal.
How virtual reality closes the understanding gap
Once diagnostics narrow the field of appropriate lens options, Dr. Ferguson's sites use a VR headset to let patients preview each candidate lens before committing. The headset simulates daytime and nighttime environments; patients can read, view a screen, or navigate a driving scene under each lens option, comparing distance, intermediate, and near function, as well as dysphotopsias, such as halos and glare.
This addresses a documented gap between how surgeons describe lens options and how patients understand them. In a randomized study across two Vance Thompson Vision offices in Fargo and Omaha, Nebraska, 233 cataract patients were assigned to a VR simulation group or a control group that received standard verbal counseling.5
Patients in the VR group chose an advanced technology IOL far more often than controls, 69 of 121 (57%) versus 29 of 112 (26%).5 In post-study validation of the same cohort, 86% of surveyed patients said their actual post-operative vision matched what they had previewed in the headset, and 93% said they would recommend the VR experience to friends or family.5
“It's nice for patients, we can tell them anything, but when they can simulate it, that is a really powerful form of education and understanding for them as they go through the evaluation.”
The same headset can also simulate monovision for interested patients and demonstrate the tradeoff of correcting versus not correcting astigmatism, letting patients see, rather than simply hear, what a lens choice means for their daily vision.
In closing
Choosing an IOL is a one-time decision with lasting consequences, and Dr. Ferguson's workflow treats it that way: a layered diagnostic workup narrows candidacy before the conversation starts, then VR simulation lets patients experience the tradeoffs of the options they actually qualify for. A patient's motivation to be spectacle-free is only useful information once paired with an accurate read on what their cornea and retina can support.
As multi-device keratometry, retinal OCT screening, and VR simulation become standard parts of the cataract evaluation, they give surgeon and patient a clearer, evidence-based basis for a decision that only gets made once.
