As part of the celebration of innovation for the 30th anniversary of Ophthalmology Management, Robert F. Melendez, MD, CEO and founder of Juliette Eye Institute and editorial board member for Ophthalmology Management, reviews the history and current applications of presbyopia-correcting intraocular lenses (PCIOLs).
This transcript has been edited for clarity.
Hello, my name is Rob Melendez. I'm a board-certified ophthalmologist from Albuquerque, New Mexico, and the CEO and founder of the Juliet Eye Institute, where we perform cataract and refractive surgery. Congratulations to Ophthalmology Management on 30 years in publication. I’m excited to participate and share a few thoughts on the history and timeline of PCIOLs to help our patients see at their very best.
I graduated from residency in 2004. Coming right out of residency was really the start of these premium lens implants, multifocal lenses, and crystal lenses. You had various brands out at that time. And the lens that we used in our practice at that time in 2004 was Alcon’s AcrySof ReSTOR +4.0. That was a multifocal lens—a great lens at distance and up close, but as for near vision, patients would report it was just too near.
So they came out with another multifocal called the AcrySof IQ ReSTOR +3.0, where the near point moved out a little bit more. Still, the vision was great at distance, but I think patients still wanted it to be moved out farther. So Alcon modified that one more time and came up with what's called the AcrySof IQ ReSTOR +2.5, where the focal point up close was moved out. And that was really more of a bifocal, multifocal lens at the time. We didn't use the word bifocal; we just used multifocal at that time.
Then, you fast-forward to modern day premium lens technology in 2019, when the AcrySof IQ PanOptix Trifocal from Alcon, the first trifocal lens implant, was introduced in the US market. They modified that lens to what's called the Clareon PanOptix Pro. My practice, along with 3 others across the country, was fortunate enough to be studying the PanOptix Pro. They had 2 samples, if you will: an alpha and a beta type. We tested those, and Alcon went to market with 1 of the 2 that's now on the market as the PanOptix Pro. That launched across the US in May of 2025. It still maintained the near, intermediate, and distance vision, but it also captured some of that light scatter that was lost with the AcrySof IQ PanOptix Trifocal. They actually recaptured it by changing the steps—the height of the steps on the trifocal lens—and that resulted in more light penetrating through the lens. I think as a result of that, in my experience, we saw that patients had lower visual symptoms at night with the Clareon PanOptix Pro compared to the AcrySof IQ PanOptix Trifocal and better contrast sensitivity; some patients were reporting some issues with that. That is the first and only trifocal lens at that time in 2019.
Now we have some other trifocal lens implants on the market, including the near-vision trifocal lens, also a very good full range of vision lenses, allowing patients to see near, intermediate, and distance. Nighttime vision profiles also improve, like with the Clareon PanOptix Pro, another really good alternative. And of course, the third trifocal lens on the market, Finevision HP, is by BVI Medical—the latest and greatest. I don't have any personal experience with that one yet, but we'll be using that lens very soon, and I'm excited to be trying that lens out.
This is such a great time to be a cataract and refractive surgeon because patients are really wanting less dependency upon glasses. There's nothing that's glasses-free as we know, but most patients with these new lens implants can see without glasses near, intermediate, and far. And it makes us and our patients happy. This is the best time for patients and surgeons, and we really appreciate the hard work of the various companies creating these new technologies to help our patients see at their very best.
There's also a newer platform of lens implants called extended depth of focus (EDOF) lenses. And we have the AcrySof IQ Vivity from Alcon and the TECNIS PureSee from Johnson & Johnson Vision (J&J) to name a couple of examples—excellent distance vision, very good intermediate, and sort of marginal near. It's mainly for distance and intermediate. Those patients tend to need reading glasses for smaller print, but font sizes that are larger than 16, these patients still see very well. The advantages of the EDOF lenses is that it's a better visual process at night, so there's fewer nighttime symptoms. So if you have patients with, let's say, a mild epiretinal membrane, some mild drusen perhaps, that might be a better lens option. There's better contrast sensitivity with the EDOF lenses as compared to the diffractive trifocal lenses. So that's a good option.
Now we have this other newer category as well known as monofocal plus. The monofocal has been out for many years, originally designed by Sir Harold Ridley and introduced into the market in 1949. That was his first lens implant in a human. We learned all this from Royal Air Force pilots when they were injured by some of the material from the actual windshield of the aircraft. That material was made out of acrylic. An ophthalmologist noted that when the pilot was injured, there were some small acrylic fragment materials from the windshield, but the pilots were not reacting to the acrylic material. That's how they came up with the idea to develop the first polymethyl methacrylate lens implant in 1949. Of course, that grew in the ’50s, and we're now moving forward.
In the mid-2020s, we have 3 trifocal lenses: EDOF lenses, monofocal plus lens implants, and torics to correct astigmatism. There's really no better time now to get your feet wet. If you're someone that's been using sort of standard monofocal lenses, I'd encourage you to start progressing to the monofocal pluses, introduce some EDOF lenses—try that and get some experience.
I think the important piece is spending quality time with the patient beforehand to understand what their needs are. Some people want to see better out at distance. There's a multifocal lens out on the market by Johnson & Johnson called the Tecnis Odyssey. It's an excellent lens for distance vision. In particular, very far distance is what I call it, 20/20, but we're talking about those patients that want to see 100 yards and beyond. They're hunters, they're ranchers, they're golfers—they want to be outdoors and see far. That's an excellent lens for intermediate and near vision. Just like any multifocal lens implant, though, there's always that rare risk of some visual symptoms at nighttime.
In summary, it's a wonderful time to be a patient now who needs cataract surgery. You have so many different choices to choose from regarding the lens implant that you want after your cataract surgery. If you're trying to be the least dependent upon glasses, then I would go with the trifocal lens. Counsel your patients thoroughly about the risk of visual symptoms at night. These do improve with time, fortunately, with neuroadaptation and with the newer trifocal lens implants. I think the visual symptoms I personally have seen in my own experience moving from the AcrySof IQ PanOptix Trifocal to the Clareon PanOptix Pro, the visual symptom profile at nighttime has improved substantially. So you can have confidence in using that lens to help your patients see at their very best.
Now, if you have patients with other ocular pathologies—such as glaucoma or macular degeneration—you may want to go with a monofocal plus lens or a monofocal plus toric lens. That's an excellent option. You can also do a Vivity if there's just some mild changes, but patients with moderate to severe vision loss typically will remain with the monofocal plus lens. We also have several EDOF lenses; the new Tecnis PureSee from Johnson & Johnson and the AcrySof IQ Vivity from Alcon are both very good extended depth of focus lenses. And then in the trifocal lens category, the Clareon PanOptix Pro, the NV Trifocal, and of course the new Finevision HP trifocal lens from BVI Medical, which I am excited to be trying very soon.
I offer lens options to all my patients. We have different lens options, including the light adjustable lens. And that's an excellent lens for many reasons for those patients who want monovision or customized monovision, and who have had prior radial keratotomy surgery or LASIK surgery. It's an excellent lens with minimal nighttime symptoms, and really probably one of the sharpest distance visions that you can get. And that's also another really good alternative.
Happy anniversary, OM. Thank you for this special opportunity to help all of us raise awareness about all these excellent lens implants that we can offer our patients.