Is an Extended Depth of Focus (EDOF) toric lens indicated for presbyopia?

EDOF Toric Lenses for Presbyopia

Yes, EDOF toric lenses are indicated for presbyopia correction, particularly in patients who have both presbyopia and corneal astigmatism requiring correction. These lenses combine extended depth-of-focus technology to address presbyopia with toric correction for astigmatism, providing functional vision across multiple distances while correcting pre-existing corneal astigmatism.

Primary Indication and Mechanism

EDOF toric IOLs serve a dual purpose in presbyopic patients:

• Presbyopia correction: Extended depth-of-focus IOLs increase functional intermediate and near vision when used in refractive lens exchange or cataract surgery 1
• Astigmatism correction: The toric component corrects preoperative regular keratometric astigmatism 1

The American Academy of Ophthalmology's 2023 Refractive Surgery guidelines explicitly state that "multifocal, extended depth of focus, or accommodative IOLs may increase functional intermediate or near vision" and that "toric IOLs may be used to correct preoperative regular keratometric astigmatism" 1

Clinical Outcomes and Evidence

Visual Performance:

• Monocular uncorrected visual acuity achieves 0.06 logMAR at distance, 0.13 logMAR at intermediate (80 cm), and 0.13 logMAR at near (40 cm) 2
• Binocular defocus curves demonstrate visual acuities of 0.10 logMAR or better for defocus levels from +0.50 to -2.50 D 2
• 95% of eyes achieve 20/25 or better uncorrected distance and intermediate vision, with 92.5% achieving 20/40 or better near vision 3

Astigmatic Correction Accuracy:

• Residual cylinder remains within ±0.50 D in 92-97% of eyes 2, 4
• Mean absolute IOL rotation is 3.79 ± 2.94 degrees, indicating excellent rotational stability 2
• Surgically induced astigmatism prediction error averages 0.04 ± 0.16 D 2

Patient Selection Criteria

Ideal candidates include:

• Presbyopic patients with regular corneal astigmatism of 0.75 to 2.19 D 2
• Patients seeking spectacle independence for multiple distances 2, 5
• Those willing to accept potential compromise in quality of vision compared to monofocal IOLs 1

Critical consideration: Surgeons must understand the individual patient's lifestyle and expectations to select the best IOL option, as there is potential compromise in quality of vision with some presbyopia-correcting IOLs compared to spheric monofocal IOLs 1

Surgical Approach Options

Mini-monovision strategy:

• Targeting the nondominant eye for -0.50 D myopia improves near visual acuity (0.25 vs 0.34 logMAR, P < .001) compared to bilateral emmetropia 4
• This approach provides slightly worse monocular distance vision (0.16 vs 0.09 logMAR, P = .002) but maintains excellent binocular distance vision 4
• Binocular near vision improves significantly with mini-monovision (0.19 vs 0.25 logMAR, P = .03) 4

Spectacle Independence and Patient Satisfaction

Functional outcomes:

• Spectacle dependence for near vision drops to 36% with EDOF IOLs compared to 80% with enhanced monofocal IOLs (P = 0.002) 5
• Significant improvements occur in all Rasch-calibrated quality of life scores (P < .001) 2
• Full restoration of visual function across different distances is achievable 2

Important Caveats

Photic phenomena:

• More frequent with EDOF lenses compared to monofocal IOLs 5
• Patients must be counseled preoperatively about potential visual disturbances 1

Contrast sensitivity:

• Remains comparable to enhanced monofocal IOLs despite extended depth of focus 5
• No significant compromise in mesopic or scotopic conditions with modern EDOF designs 5

Astigmatism management:

• For low astigmatism (< 0.75 D), consider whether toric IOL or corneal relaxing incisions are more appropriate based on economic factors and patient comorbidities 6
• Toric IOLs provide lower residual astigmatism than nontoric IOLs even when corneal relaxing incisions are used 1