Comment on: Incidence and factors for pseudoaccommodation after monofocal lens implantation: the Monofocal Extended Range of Vision study

We read with interest the article by Nanavaty et al.¹ We had also been noticing just like everybody else that previous to the era of multifocal and trifocal and extended depth-of-focus intraocular lenses (IOLs), after implantation of monofocal IOLs, certain eyes somehow attained multifocality, the so-called extended range of vision, and such patients would be extremely satisfied (unpublished data).

The trifocal IOLs work on the principle of distribution of light energy to various (3) focal points, thereby compromising the contrast/quality of vision and sometimes giving rise to dysphotopic symptoms.² Although in real-world scenario, we generally see that patients with significant cataract undergoing an uncomplicated surgery with trifocal IOL implantation and having no significant residual error postoperatively are usually quite satisfied. We have seen that even patients who have a compromised visual potential and contrast such as from advanced glaucoma, when they undergo a flawless cataract surgery with trifocal IOL implantation, are usually satisfied (all our patients in this study were satisfied with the visual result).³

As rightly pointed out by the authors, if the factors responsible for pseudoaccommodation and increased depth of focus can be identified, these can be incorporated into the newer IOLs with minimal side effects such as compromised contrast and dysphotopsia. We have always thought and wondered that it would be best to be able to bring about multifocality from naturally occurring principles of physics inside the eye such as those enumerated in the study by Nanavaty et al.—low myopic spherical equivalent, lower total eye spherical aberration, shorter preoperative axial length, and smaller pupil size.¹ Perhaps it may be a good idea to mimic and take help of these laws of physics that are going on inside the eye and incorporate into the IOLs.

I commend the authors to have brought out this very pertinent question of pseudoaccommodation and to take its help to develop extended range-of-vision IOLs. The industry must take note/cognizance of it and try and develop IOLs taking these principles into account. This may give the best of results and, hence, better subjective acceptability of IOLs. We will, hence on, inch towards a more ideal IOL.