Surgical Correction of Presbyopia

Lenticular, Corneal, and Scleral Approaches

Michael Greenwood, MD; Shamik Bafna, MD; Vance Thompson, MD


Int Ophthalmol Clin. 2016;56(3):149-166. 

In This Article

Accommodation IOLs

Accommodating IOLs aim to correct presbyopia by altering the focal length of the IOL-eye optical system by anterior movement of the lens.[64] The Crystalens by Bausch+Lomb (Aliso Viejo, CA) is a single-optic lens with plate-style haptics that features flexible hinges, allowing anterior motion of the optic. The initial clinical trial stated that there was approximately 1.0 D of accommodation present,[64] but there has been much debate regarding the mechanism of action and how much accommodation is actually achieved. Recent data support good outcomes with 71% and 69% of patients able to read J2 or better at intermediate and near, respectively.[65] A toric version of this lens is also available, which is called the Trulign Toric IOL, which allows for simultaneous correction of presbyopia and astigmatism. It is currently FDA and CE approved. A recent study demonstrated that this IOL was safe and effective in reducing the effects of preoperative corneal astigmatism and provided excellent uncorrected distance and intermediate vision and functional near vision.[66]

Because this platform uses a monofocal IOL, there is less optical scatter, which results in fewer visual symptoms and photic phenomena when compared with a multifocal IOL.[67] However, there is less near add when compared with the multifocal IOLs. A Cochrane review noted that a disadvantage of this lens is a higher rate of PCO, but the effect of PCO on the IOL mechanism and vision was not known. IOL tilting has been reported after uneventful cataract surgery, and can result in a "Z syndrome," named due to the confirmation of a Z-shape in the capsular bag by the IOL.[68] Because the Z syndrome is caused by capsule fibrosis primarily, every effort to reduce the occurrence of capsule fibrosis intraoperatively must be made using an appropriately sized capsulorhexis, cortical removal, and, potentially, capsule polishing.[69] The authors of this paper advocate early nd:YAG laser capsulotomy to prevent any lens tilting. If a Z-syndrome occurs, selective nd:YAG laser capsulotomy, IOL reposition, or IOL exhange can be performed.[70]