From EDOF to trifocals, surgeons unleashed a spectrum of presbyopia solutions aimed at optimizing outcomes across patient types.
Presbyopia: Seeing it all—now that’s easier said than done. On Day 3 of APACRS 2025, this Saturday session lived up to its name, putting premium IOLs and laser-based solutions under the microscope.
Chaired by Dr. Sri Ganesh (India), Dr. John Chang (Hong Kong SAR, China) and Dr. Pannet Pangputhipong (Thailand), the symposium featured a globe-spanning lineup of speakers tackling the multifaceted quest to correct near vision loss.
With presbyopia affecting hundreds of millions worldwide, the hunt for presbyopia solutions has never been more urgent. For those who couldn’t attend this optical odyssey, here’s a look at the highlights that brought clarity into focus.
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A tale of two lenses
Extended depth of focus (EDOF) technology took center stage as Dr. Gerard Sutton (Australia) compared TECNIS PureSee (Johnson & Johnson; Florida, United States) with AcrySof IQ Vivity (Alcon; Texas, United States). His audit of 50 PureSee patients at 3 months, contrasted with longer-term Vivity experience, offered a revealing head-to-head comparison.
Both lenses delivered impressive results, with nearly three-quarters of patients achieving 20/20 distance vision and N6 near acuity bilaterally. Vivity showed a slight edge at distance, while PureSee performed better at near, though Dr. Sutton emphasized that “in terms of the actual results, they were pretty identical.”
The PureSee’s intermediate performance was particularly notable, with 82% of eyes achieving N5 or better. Perhaps most significant was PureSee’s pupil-independent performance. “The PureSee will prove to be much less pupil dependent,” Sutton noted, giving patients more reliable reading vision “when the pupil is getting larger”—a practical advantage when the lights go down and dinner menus come out.
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A necessity, not a lifestyle choice
Dr. Smita Agarwal (Australia) took a panoramic view of presbyopia correction, framing it not as elective enhancement, but as an inevitable clinical need. With 2.1 billion people expected to be affected by 2030, the burden is more than just blurry menus, it’s a $11 billion hit to global productivity and a 22% dent in quality of life.
Dr. Agarwal mapped out current strategies, from types of laser blended vision (LBV) or multifocal laser eye surgery like PresbyMAX (SCHWIND eye-tech-solutions; Kleinostheim, Germany) and PRESBYOND (Carl Zeiss Meditec AG; Jena, Germany) to refractive lens exchange (RLE), phakic lenses, EDOF and multifocal IOLs. In her small matched study, PRESBYOND showed better contrast, near and intermediate vision than PresbyMAX, though the sample was too small for statistical significance. Lens-based options expand the toolkit, from monovision and EDOF IOLs to multifocals, but patient selection and preoperative counselling are key.
The secret to success, she stressed, lies in individualized planning and managing expectations. “Choosing the right eye for the right patient is key,” she advised, warning that even minor residual astigmatism can sabotage outcomes. Her candid conclusion captured the current reality: “It’s presbyopia options, not solutions—until it is inevitable.”
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A balancing act with binocular benefits
Mixing and matching premium IOLs is not about playing matchmaker, but about expanding the binocular defocus curve to cover the full range of vision, argued Dr. Chitra Ramamurthy (India). Her presentation traced the evolution from bifocals (with their 20% light loss and poor intermediate vision) to modern trifocals, which redistribute light more efficiently. With no “perfect” lens, combining complementary technologies across eyes can often deliver better outcomes.
Survey data revealed a professional split: 44% of surgeons favor this approach, while 46% remain skeptical. She sketched the broad strokes of popular combinations like Vivity in the dominant eye paired with PanOptix (Alcon; Texas, United States) in the non-dominant, or complementary systems likeMini Well and Mini Well Proxa (SIFI; Catania, Italy).
“Let us not shun the concept of mix and match,” Dr. Ramamurthy urged. “Understand the optic principles of each lens and utilize them to our advantage—and customize to what the patient wants.” The goal: stretching the binocular defocus curve to suit individual patient needs without sacrificing quality.
Seeing clearly through complexity
Presbyopia correction in eyes with complex corneas demands a delicate diagnostic dance, and Dr. Aanchal Gupta (Australia) offered a sharp reminder that you can’t treat what you don’t detect. Whether it’s keratoconus, post-refractive irregularity or subtle anterior pathology, missing corneal red flags can send even the best IOL strategy off-course.
Her approach starts with careful history (monocular diplopia, fluctuating vision), meticulous topography and ocular surface assessment. In one case study, missed anterior basement membrane dystrophy led to poor outcomes until phototherapeutic keratectomy (PTK) cleared the way for successful PureSee implantation. For keratoconus, Dr. Gupta favors the Barrett True-K (KCN) formula and her published work combining intracorneal rings with topography-guided PRK showed significant improvements.
Still, she warned against overreliance on “rescue” technologies like IC-8 lenses in severely irregular eyes. “If a regular cornea is achieved, you can potentially use almost any IOL,” she said. “But if there’s a risk of recurrence, be very cautious with multifocals.” Her guiding principles were to identify, classify and optimize before implanting.
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Twelve years of trifocal truth
For Dr. Matteo Piovella (Italy), trifocal IOLs constitute a revolution “bigger than phacoemulsification.” Reviewing 12 years of outcomes with the ZEISS AT LISA trifocal (Carl Zeiss Meditec AG; Jena, Germany), he emphasized that success hinges less on advanced optics than on fundamentals: precise biometry, meticulous ocular surface preparation and eliminating anisometropia. “When patients are within half a diopter, there are no complaints,” he said.
Dr. Piovella’s practice has embraced trifocals for their astigmatism-correcting power (up to 12 D) and proven near vision performance, with over 45% of his implants correcting at least 1 diopter of astigmatism. Precision is non-negotiable: 98% of his patients hit the emmetropic target (≤0.5 D), with stable acuity and no significant contrast sensitivity loss long-term.
His routine now includes aggressive management of dry eye and meibomian gland dysfunction with ILOX, IPL or LipiFlow before surgery. Having implanted a trifocal in his own eye 11 years ago, Dr. Piovella’s confidence in the technology speaks volumes as both a surgeon and a patient.
Old cuts, new optics
Implanting premium IOLs in post-laser eyes remains a gray zone, said Dr. Ruth Lapid-Gortzak (Netherlands), largely because high-quality evidence is lacking. A 2022 meta-analysis of 445 eyes found strong distance (98%) and intermediate (99%) spectacle independence, but weaker near outcomes (78%) and only 66% within ±0.5 D of target. Eyes with prior LASIK, PRK or other corneal reshaping procedures carry altered spherical aberrations, making IOL selection delicate.
“If the previous ablation was higher than 5 diopters myopic or 2 diopters hyperopic, I lost this boxing match—I prefer not to implant a premium IOL,” she admitted. Her approach involves matching the patient’s corneal aberration profile with specific multifocal designs using tools like iTrace and ray-tracing aberrometry.
Diffractive designs generally outperform refractive or asymmetric ones in post-laser corneas, but Dr. Lapid-Gortzak warned against overcomplicating already complex optics. “The goal isn’t just to implant a multifocal—it’s to implant the right one,” she noted. Sometimes an EDOF is a reasonable fallback, and sometimes saying no is the best option, because dissatisfaction must always be “on the menu.”
Cracking the code on clear vision
Presbyopia may be inevitable, but its correction is anything but one-size-fits-all. From EDOF comparisons and presby-LASIK studies to mix-and-match strategies and long-term trifocal outcomes, this APACRS 2025 session showcased both progress and pitfalls, reminding us that personalization is the new standard.
Whether you’re working with virgin corneas or post-refractive puzzles, the success lies in careful diagnostics, expectation management and matching technology to anatomy—not hype. As we continue chasing the holy grail of presbyopia correction, the most valuable insight is knowing when to implant a premium lens, which one to choose and occasionally, when to walk away. That, it seems, is what “seeing it all” is really about.
Editor’s Note: The 37th annual meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2025) is being held from 21-23 August in Ahmedabad, India. Reporting for this story took place during the event. This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.