Use of Partial Range of Field Intraocular Lenses in Eyes with Macular Disease

Abstract

This comprehensive review evaluates the current evidence and expert opinion regarding the use of extended depth of focus (EDOF) intraocular lenses (IOLs) in patients with macular disease. A literature review and a survey of European Society of Cataract and Refractive Surgeons (ESCRS) committee members were conducted. The review found a growing body of evidence suggesting potential benefits of EDOF IOLs in selected patients with mild to moderate macular disease, although concerns remain. The survey found that while 59% of respondents considered EDOF IOL implantation in this population “worth trying”, only 37% reported performing the procedure occasionally, and a minority did not consider it at all. Further research is needed to determine optimal patient selection criteria and long-term outcomes for EDOF IOLs in eyes with macular pathology.

Zusammenfassung

In dieser Übersichtsarbeit werden die aktuelle Evidenz und Expertenmeinungen zum Einsatz von Intraokularlinsen (IOL) mit erweiterter Tiefenschärfe (EDOF) bei Patienten mit Makulaerkrankungen evaluiert. Es wurde eine Literaturrecherche und eine Umfrage unter den Komiteemitgliedern der European Society of Cataract and Refractive Surgeons (ESCRS) durchgeführt. Die Analyse ergab, dass es zunehmend Evidenz für den potenziellen Nutzen von EDOF-IOLs bei ausgewählten Patienten mit leichter bis mittelschwerer Makulaerkrankung gibt, auch wenn weiterhin Bedenken bestehen. Die Umfrage ergab, dass zwar 59% der Befragten die EDOF-IOL-Implantation bei dieser Patientengruppe für „einen Versuch wert“ hielten, aber nur 37% angaben, das Verfahren gelegentlich anzuwenden und eine Minderheit es überhaupt nicht in Betracht zog. Weitere Untersuchungen sind erforderlich, um die optimalen Kriterien für die Patientenauswahl und die Langzeitergebnisse von EDOF-IOLs bei Augen mit Makulaerkrankungen zu ermitteln.

Keywords

intraocular lens - extended depth of focus - macular disease - clinical decision making

Schlüsselwörter

EDOF - IOL - Intraokularlinsen - Makulaerkrankung

Introduction

Historically, the presence of macular disease was considered a relative contraindication for the implantation of any advanced technology intraocular lenses (IOLs), mostly presbyopia correcting IOLs. This stance was primarily based on concerns about compromised visual outcomes and potential exacerbation of existing visual disturbances. However, recent studies and clinical experience have begun to challenge this contraindication, suggesting a paradigm shift towards a more nuanced, patient-specific approach.

The rationale behind this shift stems from the unique optical properties of some of the subgroups of presbyopia correcting IOLs. These more recently introduced IOLs, which provide a continuous range of vision with less light distribution across multiple focal points in comparison to diffractive multifocal IOLs (MIOL) are also referred to as partial range of vision IOLs [1]. In an attempt to have a more evidence-based grouping of presbyopia correcting IOLs, the ESCRS has recently published a classification based on cluster analyses of the defocus curves of presbyopia correcting IOLs [2]. One group of these IOLs are the extended partial range of vision IOLs, also previously referred to as extended depth of focus (EDOF) IOLs [2], [3], [4]. Their optical characteristics may make them more forgiving in the presence of macular disease. As noted in previous studies, some patients with retinal disease who would not qualify for diffractive MIOL may be considered for refractive EDOF IOLs, although this requires careful patient selection and management of expectations [5].

An important consideration in the use of refractive EDOF IOL, which use refractive optics to extend the depth of focus, in patients with macular diseases is the potential for neural adaptation. The human visual system has demonstrated remarkable plasticity, even in the presence of retinal pathology. While research specifically addressing neural adaptation to refractive EDOF IOL in macular disease patients is not available, studies on neural adaptation in age-related macular degeneration (AMD) and other macular diseases suggest that the brain can compensate to some degree retinal dysfunction and the patient may profit from a broader range of vision without glasses [6], [7], [8], [9]. This adaptive capacity may play a role in the visual outcomes of patients with macular disease who receive refractive EDOF IOLs. However, it is important to note that the extent and speed of neural adaptation may vary significantly among individuals and may be influenced by factors such as the severity and progression of the respective macular disease.

Despite the growing interest in EDOF IOL for patients with macular disease, several knowledge gaps persist in the current literature. Most studies on EDOF IOLs in patients with macular disease have relatively short follow-up periods [10], [11], [12], [13]. There is a need for long-term studies to assess the durability of visual outcomes and potential progression of macular disease along with comprehensive assessments of the quality of life. Additionally, while some studies have included patients with mild dry AMD or stable and mild epiretinal membrane (ERM), there is limited data on EDOF IOL performance across a broader spectrum of macular diseases [13]. Furthermore, additional research is needed to directly compare the performance of EDOF IOLs with monofocal IOLs and other IOLs in patients with various macular pathologies.

Addressing these knowledge gaps is crucial for developing evidence-based guidelines for the use of EDOF IOL in patients with macular disease. As the field continues to evolve, a more refined understanding of the interplay between EDOF IOL technology and macular pathology will enable ophthalmologists and refractive surgeons to make more informed decisions and provide optimal visual outcomes for this challenging patient population.

To the best of our knowledge, no comprehensive review articles have investigated the use of EDOF IOLs in patients with preexisting retinal or macular changes, despite the significant clinical implications of this topic. This knowledge gap is particularly important given that refractive cataract surgeons frequently encounter decisions regarding IOL selection for patients with concurrent retinal pathologies and the wish for the highest possible independence from glasses. The absence of robust evidence and consensus guidelines in this domain results in disparate practices and suboptimal outcomes for this challenging patient cohort. Moreover, no prior research has collectively obtained the opinions and personal clinical routines of international high-volume surgeons and scientists in the field regarding this specific issue. By examining both the existing literature and the perspectives of leading experts, our investigation aims to provide insights that can inform clinical decision-making and potentially improve visual outcomes for patients with coexisting cataract and retinal disease.

Methods

To conduct a comprehensive literature review on the use of EDOF IOL in patients with macular diseases, we conducted a multifaceted approach to identify, evaluate, and synthesize relevant research. Our methodology involved an extensive search of high-impact ophthalmology journals and databases, including PubMed/MEDLINE and Google Scholar. The search strategy employed a combination of keywords, covering IOL technology, macular pathologies and outcome, and including “extended depth of focus intraocular lens”, “EDOF IOL”, “extended partial range of vision IOLs”, “macular diseases”, “macular degeneration”, “epiretinal membrane”, “cataract surgery”, “visual outcomes” and “patient satisfaction”. To ensure the inclusion of the most current and recent information, our primary focus was on articles published within the last decade (2014 – 2024). Nevertheless, landmark papers published earlier were also considered if they offered foundational knowledge or long-term follow-up data crucial to understand the topicʼs evolution. The selection process was conducted according to predefined inclusion and exclusion criteria. Original research articles, systematic reviews, and meta-analyses focusing on EDOF IOL in patients with macular diseases were included in the review, if they were published in peer-reviewed journals. Studies focusing solely on other types of presbyopia correcting IOL (e.g., multifocal, monofocal plus), non-English language publications, unpublished data, and conference abstracts were excluded to maintain the quality and relevance of the review.

To complement the existing literature and gain insights into current clinical practices and expert opinions, we conducted a survey of the European Society of Cataract and Refractive Surgeons (ESCRS) committee members. The objective of this survey was to assess the attitudes of international experts in refractive cataract surgery towards the use of EDOF IOL in patients with macular disease.

By synthesizing the findings from a comprehensive literature review and the survey of experts, we aimed to provide a holistic overview of the current state of knowledge regarding EDOF IOL in patients with macular disease. This approach enabled us to identify common themes, areas of consensus, and points of controversy within the field. Particular attention was paid to the evolution of clinical practices, emerging trends, and areas requiring further research, thereby offering a nuanced and up-to-date perspective on this complex topic.

Literature Overview

The application of premium IOL in patients with retinal pathologies has long been a subject of debate and caution in the field of ophthalmology. It is therefore imperative to examine the evolving perspectives on the use of advanced IOL technologies, particularly EDOF IOL, in patients with various retinal conditions. The use of AT IOLs, such as MIOL, has traditionally been discouraged in patients with retinal disorders. However, recent studies have begun to challenge this conventional wisdom. A review by Grzybowski et al. suggests that MIOL may offer benefits in terms of visual-related outcomes and patient satisfaction, even in the presence of retinal pathology [5]. This shifting perspective underscores the need for a more nuanced approach to IOL selection in patients with compromised retinal function.

To address the limitations of the existing literature, it is imperative to differentiate between the various macular diseases and their potential suitability for advanced technology AT IOLs. Age-related macular degeneration (AMD), epiretinal membranes (ERM), and diabetic macular edema (DME) represent the most commonly encountered macular pathologies in the context of cataract surgery. [Table 1] summarizes the key results of studies on EDOF IOLs in retinal diseases.

Table 1 Summary of key studies on EDOF IOLs in retinal diseases.

Study	Retinal disease/severity	Number of eyes (study design)	IOL type	Follow-up	Main visual outcomes	Patient satisfaction	Complications
Álvarez-García et al., 2023 [12]	mild maculopathy	106 eyes (prospective) and 30 eyes (retrospective)	various EDOF (e.g., Symfony, Vivity)	prospective: 8.0 ± 7.7 months; retrospective: 37.9 ± 16.2 months	prospective: CDVA: 0.07 ± 0.14 logMAR; CNVA: 0.08 ± 0.13 logMAR retrospective: CDVA: 0.07 ± 0.10 logMAR; CNVA: 0.08 ± 0.09 logMAR	NAVQ scores: prospective: 85.5% moderately to completely satisfied; retrospective: 90% moderately to completely satisfied	None reported
Reitblat et al., 2024 [13]	mild dry AMD; stable mild ERM	133 eyes (retrospective case-control)	Symfony	49 ± 27 days	UDVA: 0.10 ± 0.09 logMAR; UIVA: 0.16 ± 0.13 logMAR; UNVA: 0.28 ± 0.17 logMAR	92% reported “excellent” or “good” visual acuity	None reported
Thananjeyan et al., 2024 [11]	AMD (early: 14%; intermediate: 33%; late: 53% incl. 63% wet AMD)	51 eyes (retrospective)	Vivity	24 months	CDVA: 0.20 ± 0.25 logMAR; DCNVA: N9 ± 5	96% satisfied; 100% improved daily activities	None reported

In a comprehensive review, Grzybowski et al. provide a critical evaluation of IOL designed particularly for AMD patients [14]. The study identified seven specialized IOL types and blue-light filtering technology, which use different strategies, including magnification and light redirection, to address the visual challenges associated with AMD. However, the authors highlight several notable limitations of these specialized IOLs, including challenges in post-operative fundus examination and a significant reliance on patient commitment to visual rehabilitation programs for optimal outcomes.

The complexity of IOL selection in patients with retinal pathologies is further highlighted by Yeu et al., who emphasize the importance of considering both objective ocular characteristics and subjective patient factors [15]. Their work focuses on challenges presented by ERM among others, which can significantly impact the predictability of postoperative refractive outcomes. Their findings underscore the need for careful consideration when contemplating AT IOL, such as EDOF IOLs, in patients with macular pathologies.

For DME patients, the use of EDOF IOL can be beneficial; nevertheless, precise patient selection and the management of underlying diabetic conditions are crucial to ensure optimal outcomes [16]. The elevated risk of postoperative complications, including cystoid macular edema, which can diminish the functional benefits of these IOLs, underscores the necessity for a careful preoperative evaluation of the patientʼs retinal status and glycemic control.

Several studies have begun to explore the potential of EDOF IOL in patients with macular pathologies. A pilot study by Thananjeyan et al. involving patients with various stages of AMD showed promising results with the AcrySof IQ Vivity EDOF IOL, with the majority of patients achieving satisfactory VA and reporting high levels of satisfaction [11]. However, the outcomes vary by disease stage. Early AMD patients achieved excellent vision (CDVA logMAR 0.11, DCNVA N8), intermediate AMD patients maintained functional vision (CDVA logMAR 0.46, DCNVA N13), and late AMD patients showed more variable results (CDVA logMAR 1.10, DCNVA N27), with better outcomes in wet AMD. Another comparative study demonstrated that while VA outcomes were superior in healthy eyes, patients with retinal pathologies still experienced significant improvements and reported similar levels of satisfaction with EDOF IOL [13]. A recent study by Álvarez-García et al. demonstrated that EDOF IOL can provide significant visual improvements and high patient satisfaction in patients, with various ocular conditions, including mild maculopathy, glaucoma, or previous vitrectomy, and who may not be ideal candidates for AT IOL [12]. Kaymak et al. further contributed to this body of evidence, demonstrating that EDOF IOL can provide significant improvements in near VA for patients with macular pathologies [17]. However, they also noted a reduction in contrast sensitivity at lower spatial frequencies, highlighting the need for careful consideration of visual performance under various lighting conditions.

Despite these encouraging findings, several challenges remain in the application of EDOF IOL in patients with retinal pathologies. Issues such as pupil dynamics, higher-order aberrations (HoA), and the potential impact of disease progression on long-term outcomes require further investigation. Additionally, the importance of proper patient selection and thorough preoperative counseling cannot be overstated.

ESCRS Committee Member Survey

A survey was conducted among members of the ESCRS committees, yielding responses from 27 participants. The objective of this survey was to evaluate the attitudes and practices of international high-volume surgeons and scientists in refractive cataract surgery regarding the utilization of EDOF IOL in patients with macular pathology.

In response to the initial inquiry, “I believe implanting an EDOF IOL into patients with moderate macular pathology (CDVA 0.5 or better) and with a desire to be spectacle independent as much as possible is…”, the responses were distributed as follows: Almost a third of respondents (8/27) considered it a beneficial procedure, indicating that even patients with macular pathology can benefit from the EDOF effect while experiencing a minimal risk of developing photopic phenomena or reduced contrast sensitivity. Most respondents (59.3%, 16/27) indicated that they viewed the procedure as a potential avenue for further exploration, suggesting that it should be discussed more broadly within the professional community. A small minority of 11.1% (3/27) of respondents indicated that the procedure was “against the ethical rules of our profession and should be avoided at any time”.

Regarding the second statement, “I personally implant EDOF IOLs in macular pathology”, the responses indicated a range of clinical practices among the participants. A minority of respondents, 7.4% (2/27), indicated that they perform EDOF IOL implantation in macular degeneration patients as part of their daily routine clinical practice. The largest group, representing 55.6% (15/27) of the respondents, indicated that they never implant EDOF IOL in such cases. The remaining 37% (10/27) of respondents indicated that they occasionally implant EDOF IOLs in patients with macular degeneration.

Discussion

This literature review and survey of ESCRS committee members revealed a nuanced perspective on the use of EDOF IOLs in patients with macular disease. While the implantation of EDOF IOLs is not yet considered standard practice in this patient population, there is growing evidence and expert opinion suggesting that it may be a viable option for selected cases, particularly when patients express a strong desire for less spectacle dependence.

The survey results indicate that a significant proportion of the surveyed international surgeons (59.3%) views the implantation of EDOF IOLs in patients with moderate macular disease as “worth trying” and a topic that warrants broader discussion within the ophthalmological community. This perspective aligns with the emerging body of literature that suggests EDOF IOLs may offer benefits in terms of visual outcomes and patient satisfaction, even in the presence of mild to moderate macular pathology. Interestingly, while only 7.4% of surveyed experienced surgeons reported implanting EDOF IOLs in patients with macular pathology as part of their routine practice, a substantial 37% indicated that they perform this procedure at least occasionally. This finding suggests that, although not yet standard practice, the use of EDOF IOLs in patients with macular pathologies routinely may be more common than previously thought and is being explored by a significant portion of experienced surgeons. However, it is essential to acknowledge that the application of EDOF IOLs in patients with macular pathologies is not without challenges. The survey revealed that 11.1% of the participants consider this practice to be against ethical rules and should be avoided. This minority opinion underscores the ongoing debate and the need for careful patient selection, thorough preoperative counseling and individualized decision-making.

The cautious approach reflected in these survey results is understandable given the historical undifferentiated declaration of retinal disease as a contraindication for presbyopia correcting IOL implantation. However, the readiness of many of the ESCRS committee members to consider EDOF IOLs in selected cases indicates a shift in perspective, shaped by advancements in EDOF technology and an expanding comprehension of its potential advantages even in complex cases. The potential benefits of EDOF IOLs in providing an extended range of vision and reducing spectacle dependence must be weighed against the possible risks and limitations in the context of macular pathology. Factors such as the type and severity of macular disease, the potential for disease progression, and the patientʼs visual expectations and lifestyle needs should all be carefully taken into consideration. It is important to note that differentiation by severity is critical. Patients with mild AMD or stable ERM may tolerate EDOF IOLs well, whereas advanced wet AMD or progressive DME eyes pose a higher risk of suboptimal outcomes due to significantly reduced contrast sensitivity and potential progression [11], [15], [16]. Furthermore, the survey results underscore the significance of ongoing research and clinical experience in this field. The fact that a majority of respondents view the use of EDOF IOLs in macular disease as a promising avenue for further investigation highlights the necessity for more comprehensive, long-term studies to establish more definitive guidelines and optimize patient outcomes.

This review is limited by the small amount of evidence on EDOF IOLs in retinal diseases. Most studies are small and non-randomized, with insufficient long-term follow-up and lacking direct comparisons to monofocal and other commonly used IOLs. While the survey gives valuable insights, it was restricted to ESCRS committee members, which limits its applicability beyond this expert group and potentially introduces a selection bias, and therefore it must be interpreted cautiously. These gaps underscore the necessity of randomized controlled trials and larger patient cohorts to validate future findings.

Conclusion

Although the implantation of EDOF IOLs in patients with macular disease is not yet routine practice, the findings of the current review – including survey data from 37% of ESCRS committee members who occasionally perform the procedure and emerging studies – indicate that it is increasingly being considered and performed in macular pathology. The increasing body of literature and the perspectives of ESCRS committee members suggest that EDOF IOLs may offer a viable option for patients with mild to moderate macular disease who desire spectacle independence. It is noteworthy that both the current scientific evidence and the opinion of the ESCRS committee members indicate that EDOF IOLs are not an absolute contraindication or a serious treatment error in macular disease. Nevertheless, this strategy necessitates careful patient selection, comprehensive preoperative assessment and transparent discourse regarding potential outcomes and limitations (expectation management).

Conflict of Interest

The authors declare that they have no conflict of interest.

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Publication History

Received: 10 May 2025

Accepted: 22 August 2025

Article published online:
17 October 2025