Economic Evaluation of Intraocular Lens Targeting Cataract Patients: A Review and Future Directions

Abstract

Purpose

Cataracts remain the leading global cause of blindness, disproportionately affecting aging populations and imposing substantial economic burdens. With the widespread adoption of intraocular lens (IOLs) implantation in cataract surgery, rigorous health economic evaluations are imperative to inform clinical decision making and resource allocation across diverse healthcare systems.

Methods

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, encompassing PubMed, Web of Science, CNKI, and other databases, alongside reports from international health technology assessment agencies (May 2024). Fourteen studies (2001–2022) across 12 countries were included after screening 436 records. Data extraction adhered to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist, with methodological quality assessed via the Drummond tool. Analyses focused on cost-effectiveness analysis (CEA), cost-utility analysis (CUA), and incremental cost-effectiveness ratios (ICERs), incorporating Markov models and sensitivity analyses.

Results

Multifocal IOLs demonstrated superior cost-effectiveness compared to monofocal IOLs, with ICERs well below established thresholds (e.g. $4805/quality-adjusted life years (QALY) in the United States vs. $50,000/QALY). Lifetime societal costs for multifocal IOLs ranged from $5780.79 to $15,944.76, yielding QALY gains of 0.16 to 0.71 and spectacle-independence rates of 86.0% to 90.9% versus 8.5% to 31.8% for monofocal IOLs. Hydrophobic acrylic lenses outperformed other materials (Nd:YAG laser intervention rates = 7.1% vs. 31.1% for hydrophilic acrylic), whereas scleral-fixated IOLs justified higher costs by preserving endothelial cells (ICER = €3.72/cell). Toric IOLs showed regional variability, with long-term cost savings in the United States ($349/QALY) but limited viability in the Netherlands (1–15% probability at €20,000/QALY). Heterogeneity arose from methodological differences, short-term utility assumptions, and contextual factors (e.g. reimbursement policies).

Conclusions

Advanced IOLs, particularly multifocal and hydrophobic acrylic variants, are cost-effective for patients prioritizing spectacle independence and long-term visual outcomes. However, economic viability is context-dependent, necessitating region-specific analyses that integrate real-world data, patient preferences, and indirect costs (e.g. productivity loss). Future research should prioritize lifecycle assessments, equity-focused models, and low- and middle-income countries’ (LMIC) perspectives to bridge existing evidence gaps and guide sustainable policy decisions.

Translational Relevance

This review bridges health economics and clinical practice by evaluating the cost-effectiveness of advanced IOLs across different healthcare systems, offering insights for optimizing IOLs selection based on patient needs and economic contexts. It also highlights critical evidence gaps in LMICs, urging future research to incorporate real-world data and patient preferences for more sustainable cataract care.

Introduction

Intraocular lenses (IOLs), commonly referred to as artificial lenses, are optical devices constructed from advanced synthetic materials. These lenses are primarily utilized in implantation procedures during ophthalmic cataract surgeries and are considered high-value medical devices with extensive clinical applications. With aging, the human lens progressively becomes opaque and cloudy, leading to significant visual impairment. Currently, cataract surgery is the most effective treatment, allowing external images to be reprojected onto the retina by replacing the original cloudy lens with an IOL, thereby enabling patients to achieve partial or complete vision restoration.¹ As global life expectancy continues to rise, many nations are witnessing an increase in the aging population and a corresponding shift in the disease burden toward non-communicable diseases (NCDs) and age-related disabilities. Cataract, recognized as the world's leading cause of blindness and a major contributor to visual impairment, has been profoundly influenced by this global epidemiological transition.² Studies have demonstrated that cataracts remained the predominant cause of global blindness in adults aged 50 years and above in 2020, affecting over 15 million individuals, accounting for approximately 45% of the 33.6 million cases of blindness worldwide.³ The average out-of-pocket cost for cataract surgery is estimated at $4131 per eye, according to the most recent data (updated August 2023).⁴ However, the per-eye cost can vary significantly based on the specific treatment received, the location of the procedure, and the expertise of the healthcare provider performing the surgery. The choice of IOLs implant is another critical determinant of the overall cost. For instance, cataract surgery involving toric IOLs incurs an additional cost of $900 to $1500. Refractive IOLs are associated with even higher costs, ranging from $1995 to $2500 per lens.

A hospital-based study on the cost of inpatient cataract surgery revealed that medical materials constituted a significant 79.88% of the total cost, with the price of IOLs identified as the most influential factor contributing to this proportion.⁵ Owing to the inherently high cost of IOLs, coupled with variations in materials, focal types, and designs, healthcare policymakers and researchers across various nations have conducted health economic evaluations (EEs) to assess cost-effectiveness and inform localized decision making. Although global reviews of EEs for cataract surgery are available,^6–7 there remains a notable gap in systematic evaluations specifically focusing on IOLs implantation treatments. IOLs are widely regarded as high-value medical consumables in regions such as the United States, Canada, Europe, Australia, New Zealand, and several Asian countries. Since May 2020, IOLs have been the most widely included medical consumable under China's “volume-based procurement” policy.⁸ However, disparities in medical insurance reimbursement ratios for different IOLs persist, and relevant EEs remain notably insufficient, particularly in low- and middle-income countries (LMICs). Therefore, this study aims to identify health EEs of IOLs conducted globally, with a focus on systematically and comprehensively analyzing the research to provide robust evidence supporting the clinical application of IOLs.

Materials and Methods

Data Sources and Search Strategy

In May 2024, a comprehensive search of the PubMed, Web of Science, Scopus, CNKI, and Cochrane databases was conducted to identify economic evaluation studies pertaining to IOLs. The search strategy incorporated keywords such as “intraocular lens,” “cost effectiveness,” “cost benefit,” “cost utility,” “economics” and “cost.” Additionally, the websites of member institutions affiliated with the International Network for Health Technology Assessment (INAHTA) were systematically explored, and pertinent reports were compiled to enhance the comprehensiveness of the literature review.

Study Selection

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to ensure comprehensive and transparent reporting.⁹ The target population for this review encompassed all individuals requiring IOL implantation for cataract treatment, irrespective of age, sex, ethnicity, or socioeconomic background. No limitations were imposed on study design; however, systematic reviews primarily aimed at summarizing cost-effectiveness, cost-benefit, or cost-utility analyses were excluded. Furthermore, health technology assessment (HTAs) incorporating an economic evaluation component were included, whereas conference abstracts, expert guidelines, and opinions were excluded.

Data Extraction

Data from included studies were extracted to an Excel spreadsheet in accordance with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).¹⁰ A prespecified data extraction form was developed to systematically capture study characteristics, costs associated with IOLs, key effectiveness indicators, measurement methods, and outcomes. The primary outcome measures included quality-adjusted life years (QALYs), spectacle-independence rates, and the incremental cost-effectiveness ratio (ICER). Costs presented in the table were derived directly from the original studies and converted to US $2024 using the Evidence for Policy and Practice Information and Coordinating Centre (EPPI Centre) calculator for comparative analyses.¹¹ Data extraction was conducted independently by pairs of researchers, with any discrepancies resolved through discussion or, if necessary, consultation with a third reviewer.

Quality Assessment

The quality and potential biases of the included studies were systematically evaluated using the Drummond Checklist,¹² a widely recognized tool in EEs. Any discrepancies in evaluations were addressed through discussion, or when consensus could not be reached, by consulting a third reviewer. The checklist, which consists of 10 clearly defined questions, provided a structured and standardized framework for assessing the methodological quality of the studies. Each question was rated as one of three possible responses: “Yes” (met the quality criterion), “No” (did not meet the quality criterion), or “Can't tell” (insufficient evidence to reach a conclusion). It is worth noting that a numeric score was not assigned to individual studies, ensuring a qualitative approach to the assessment process. Studies were categorized as high quality if they fulfilled at least 80% of the criteria across the quality assessment tools, moderate quality if they met 60% to 79.9%, and low quality if they met less than 60%.¹³

The reporting quality of the included studies was evaluated in accordance with the revised CHEERS 2022 statement, ensuring a systematic and comprehensive appraisal. The updated CHEERS checklist encompasses 28 specific items, which are organized into 7 overarching categories: (i) title, (ii) abstract, (iii) introduction, (iv) methods, (v) results, (vi) discussion, and (vii) other relevant information. Because the CHEERS checklist evaluates the quality of reporting in EE studies rather than their quality of its conduct, a qualitative assessment was conducted to examine the completeness of reporting for each item in the included studies.¹⁰

Results

Literature Search Results

The literature search yielded 436 citations, of which 332 were removed as duplicates, leaving 104 unique records for screening. Of these, 20 studies were selected for full-text review and evaluated for eligibility. Ultimately, 14 studies^14–27 published between 2001 and 2022 were included, comprising 12 primary studies and 2 HTA reports, spanning 4 continents and 12 countries or regions (see the Fig.).

Figure.

PRISMA flow diagram illustrating literature research and selection process.

Study Characteristics

The primary perspectives analyzed were those of society and the healthcare system (Table 1). Additional perspectives included those of medical insurance providers, patients, and private health funds. The majority of studies assessed the cost-effectiveness of multifocal IOLs relative to monofocal IOLs in the context of cataract surgery. Additionally, we identified comparisons across three groups: toric IOLs versus monofocal IOLs for treating corneal astigmatism, monofocal versus multifocal IOLs, and rigid versus foldable IOLs. Further studies examined the implantation techniques of IOLs in cataract surgery and the cost-effectiveness associated with different lens materials.

Table 1.

Basic Characteristics of the Included Studies

Authors	Publication Year	Region	Perspectives	Design	Main Outcome	Research Methods	Time Horizon	Main Variables Evaluated	Discount Rate	Fundings
Afsar AJ et al.	2001	United Kingdom	—	A prospective, randomized study	A foldable IOL versus a rigid IOL	Economic costs	2 y	Post-operative costs	—	Supported by a research scholarship provided by The College of Optometrists
Smith AF et al.	2005	France, Italy, Germany and Spain	Health System (Sickness Funder State Insurance)	A retrospective study	IOL material hydrophobic acrylic, polymethylmethacrylate (PMMA), hydrophilic acrylic and silicone	CEA	3 y	ICER	0%	Supported by an unrestricted grant from Alcon Laboratories Inc., Texas, USA
Maxwell WA et al.	2008	United States	Patients	A decision tree	Apodised, diffractive, presbyopia-correcting multifocal IOL compared to a conventional	CBA*	—	WTP	3%	Supported by a grant from Alcon Laboratories, Inc., Fort Worth, Texas, USA
Lafuma A et al.	2008	France, Italy, Germany and Spain	Society and Sickness Funds (SFs)	Markov model	The multifocal IOL ReSTORÒ versus monofocal IOLs	CEA	Lifetime	PRO/costs	3%	Supported by an unrestricted grant from Alcon France SA, Rueil-Malmaison, France
Pineda R et al.	2010	United States	—	A decision tree	VA among patients with cataract and preexisting astigmatism treated with toric IOLs	CEA/CUA	Lifetime	QALY/UCVA	3%	Support by Alcon Laboratories, Inc
De Vries NE et al.	2010	The Netherlands	Society and the National Health Service (NHS)	Markov model	Bilateral monofocal (SI40NB) or multifocal (ReSTOR or Array-SA40) IOL	CEA	—	Spectacle independence rate/VA	4%	Supported by a grant from Alcon France SA, Rueil-Malmaison, France
Lin JC et al.	2014	Taiwan, China	Patients	A prospective nonrandomized study	Monofocal versus multifocal IOL	CEA	—	VA, NEI VFQ-25, and spectacle-independence rates/ICER	—	Dr C-J. Hsieh provided relevant information associated with this study
Kristianslund O et al.	2019	Norway	Healthcare provider	A randomized clinical trial	IOL repositioning versus IOL exchange	CEA	6 mo	CDVA/VF-14/QALY	0%	Partly supported by the Norwegian Extra Foundation for Health and Rehabilitation, Oslo, Norway, and South-Eastern Norway Regional Health Authority, Norway
Hu JQ et al.	2019	United States	A societal and health care sector	Markov model	Multifocal IOL versus monofocal IOLs	CEA	—	QALY/ICER/WTP/halos/glare	3%	Partially supported by the National Institutes of Health, Grant TL1TR001443
Simons RWP et al.	2019	The Netherlands	A societal and health care sector	A prospective cost-effectiveness analysis	Toric versus monofocal IOL	CEA	Lifetime	ICER/QALY/HRQL/HUI3/UDVA/CDVA/Distance spectacle independence/WTP	4%	Supported by the Ministry of Health, Welfare, and Sport and the Netherlands Organization for Health Research and Development
Bala C et al.	2022	Australia	Private health fund	Markov model	AcrySof IQ Vivity EDOF (DFT015) versus monofocal aspheric IOL (SN60WF IOL)	CEA	30 y	VA/QALY/ICER	5%	Sponsored by Alcon Vision LLC, Fort Worth, Texas, USA
Ranno S et al.	2022	Italy	Sanitary system	A retrospective, observational study	Secondary anterior chamber intraocular lens (AC-IOL) versus secondary scleral fixated intraocular lens (SF-IOL)	CEA	2 years	CDVA/VF-14/ECD/ICER	—	None to disclose
HQO	2009	Canada	MOHLTC	Markov model	Multifocal IOL versus monofocal IOLs (both made of hydrophobic acrylic material and foldable in form); hydrophobic acrylic lenses versus silicone lenses	CEA/CUA	14 y	VA/QALY/ICER	5%	Supported by the Ontario Health Technology Advisory Committee
HTAIn	2018	India	A societal and health sector	A cohort study	Rigid PMMA lenses versus foldable acrylic lenses	CEA	Lifetime	ICER/Net Health Benefit/QALY/QOL/VA	3%	Supported by Health Technology Assessment in India (HTAIn) Secretariat, Department of Health Research, Ministry of Health and Family Welfare

AC-IOL, secondary anterior chamber intraocular lens; CDVA, corrected distance visual acuity; CEA, cost-effectiveness analysis; CUA, cost-utility analysis; DALY, disability-adjusted life year; EDOF, extended depth of focus; ICER, incremental cost-effectiveness ratio; IND VFQ 33, 33-item Indian Vision Function Questionnaire; IOL, intraocular lens; NEI-VFQ-25, National Eye Institute 25-item Visual Function; PRO, patient-reported outcomes; QALY, quality-adjusted life year; Questionnaire; ECD, endothelial cell density; SF-IOL, secondary scleral fixated intraocular lens; UCVA, uncorrected visual acuity; VA, visual acuity; VRQOL, Virtual Reality Quality of Life; WTP, willingness to pay.

^*Maxwell et al. (2008) was categorized as a CBA as it used willingness-to-pay (WTP) estimates for spectacle independence and reported outcomes in monetary units, rather than health outcomes such as QALYs, which are typical of CEAs.

Methodology Analysis

Regarding research methodologies, the majority of studies used cost-effectiveness analysis (CEA) as their primary approach. A study conducted in the United Kingdom (2001) directly compared economic costs using hospital data, whereas studies from the United States (2008) and India (2020) used cost-benefit analysis (CBA) and cost-utility analysis (CUA), respectively. Other studies, such as the United States (2010) study and the Canadian Health Quality Ontario (HQO; 2009) HTA, highlighted that although CUA accounts for spectacle requirements for both near and distance vision correction post-IOL implantation, certain associated costs were overlooked. Consequently, CEA was conducted as a complementary analysis to address these gaps.

Research design primarily focused on modeling approaches, with five studies utilizing Markov models and two using decision tree analyses. In studies using Markov models, patient health statuses were primarily categorized by spectacle independence and visual disturbances, and the lifelong simulation was carried out. An analysis of studies comparing multifocal and monofocal IOLs, all using Markov models,^17,19,22 identified four primary post-surgical health states: “No need for glasses,” “Purchase glasses,” “No glasses purchased,” and “Death” as the absorbing state. A study conducted in the United States (2019) introduced an additional state, “Glare and Halo,” within each of the four primary Markov health states. In HTAs comparing multifocal and monofocal IOLs, the HQO (2009) Markov model incorporated a total of 10 distinct health states.²⁶ Furthermore, prospective research designs were more commonly used than retrospective approaches. These included randomized clinical trials, cohort studies, and observational longitudinal studies.

Quality Assessment

Specific concerns on the Drummond checklist showed that most studies did not accurately measure the costs and consequences or justify that the valuation costs and consequences were credible (Table 2). Eight studies were assessed as high quality, one as moderate quality, and five as low quality. Overall completeness of incorporated studies was relatively good (Table 3), with a median of 86.86% of CHEERS checklist items met (range = 60.87%–96.30%).

Table 2.

Quality Evaluation by Drummond Checklist

Drummond Criteria	Afsar AJ, 2001	Smith AF, 2005	Maxwell WA, 2008	Lafuma A, 2008	Pineda R, 2010	De Vries NE, 2010	Lin JC, 2014	Kristianslund O, 2019	Hu JQ, 2019	Simons RWP, 2019	Bala C, 2022	Ranno S, 2022	HQO, 2009	HTAIn, 2018
1. Well-defined question?	Can't tell	Yes	Yes	Yes	Can't tell	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
2. Adequate description of comparators?	Yes	Yes	Can't tell	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
3. Evidence of effectiveness?	Can't tell	Yes	Can't tell	Yes	No	Can't tell	Yes	Yes	Can't tell	Yes	Yes	Yes	Can't tell	Yes
4. Relevant costs/consequences?	Yes	No	Yes	Can't tell	No	Yes	No	Can't tell	Yes	Yes	Yes	Yes	Yes	Can't tell
5. Costs/consequences accurately measured?	Can't tell	Yes	No	Yes	Can't tell	Can't tell	Can't tell	Yes	Yes	Can't tell	Can't tell	Yes	Yes	Can't tell
6. Were the valuation costs/consequences credible?	Can't tell	Yes	Can't tell	Yes	Can't tell	Yes	Can't tell	Yes	Yes	Yes	Yes	Yes	Can't tell	Yes
7. Was discounting used as appropriate?	No	No	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	No	Yes	No
8. Were incremental analyses appropriately reported?	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
9. Were sensitivity analyses reported?	No	Yes	Can't tell	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	No	Yes	No
10. Was the discussion adequate?	Yes	Yes	Can't tell	Can't tell	Yes	Can't tell	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Can't tell
Percent of criteria met (%)	40	80	40	80	50	70	50	90	90	90	90	80	80	50

“Yes” represents met the quality criterion. “No” represents not met the quality criterion. “Can't tell” represents insufficient evidence to reach a conclusion.

Percent of criteria met (%) = numbers of “Yes” / 10 * 100%.

Table 3.

Completeness Evaluation by the CHEERS Checklist

	Study
Item	Afsar AJ, 2001	Smith AF, 2005	Maxwell WA, 2008	Lafuma A, 2008	Pineda R, 2010	De Vries NE, 2010	Lin JC, 2014	Kristianslund O, 2019	Hu JQ, 2019	Simons RWP, 2019	Bala C, 2022	Ranno S, 2022	HQO, 2009	HTAIn, 2018
Title
Title	1	1	1	1	1	1	1	1	1	1	1	1	N/A	N/A
Abstract
Abstract	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Introduction
Background and objectives	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Methods
Health economic analysis plan	0	1	1	1	1	0	0	1	0	1	1	0	1	1
Study population	0	1	1	1	1	1	1	0	0	1	1	1	1	1
Setting and location	1	1	1	0	0	1	1	1	0	1	1	1	1	1
Comparators	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Perspective	0	1	1	1	0	1	1	1	1	1	1	0	1	1
Time horizon	1	1	0	1	1	0	0	1	0	1	1	1	1	1
Discount rate	0	1	1	1	1	1	0	1	1	1	1	0	1	1
Selection of outcomes	N/A	1	1	1	1	1	1	1	1	1	1	1	1	1
Measurement of outcomes	N/A	0	1	1	1	1	1	1	1	1	1	1	1	1
Valuation of outcomes	N/A	1	1	1	1	1	1	1	1	1	1	1	1	1
Measurement and valuation of resources and costs	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Currency, price, date and conversion	0	1	0	1	0	1	0	1	1	1	1	0	1	1
Rationale and description of model	N/A	N/A	1	1	1	1	N/A	N/A	1	N/A	1	N/A	1	N/A
Analytics and assumptions	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Characterizing heterogeneity	1	1	1	0	1	1	1	1	1	1	0	1	1	1
Characterizing distributional effects	0	1	1	1	1	1	1	1	1	1	1	1	1	1
Characterizing uncertainty	0	1	1	1	1	1	0	1	1	1	1	0	1	0
Approach to engagement with patients and others affected by the study	1	0	0	0	1	0	0	1	0	1	0	1	0	1
Results
Study parameters	N/A	N/A	1	1	1	1	N/A	N/A	1	N/A	1	N/A	1	N/A
Summary of main results	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Effect of uncertainty	0	1	1	1	1	1	0	1	1	1	1	0	1	0
Effect of engagement with patients and others affected by the study	0	0	0	0	1	0	0	0	1	0	0	0	1	0
Discussion
Study findings, limitations, generalizability, and current knowledge	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Other relevant information
Source of funding	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Conflicts of interest	1	1	1	1	1	1	1	1	1	1	1	1	1	1
Total	14	23	24	24	25	24	19	24	23	25	25	19	26	22
Percentage (%)	60.87	88.46	85.71	85.71	89.29	85.71	69.23	92.31	82.14	96.15	89.29	73.08	96.30	88.00

“0” represents not reported. “1” represents reported. “N/A” represents not applicable.

Percentage (%) = numbers of “1” / (28 - numbers of “N/A”) * 100%.

Multifocal Versus Monofocal IOLs

The economic evaluation of multifocal IOLs across various countries reveals significant variation in both costs and cost-effectiveness. From a societal perspective, the cost of a multifocal IOL (MF IOL) ranged from $5780.79 to $15,944.76, and the cost for a monofocal IOL was $5063.22 to $11,843.58 (Table 4). In Europe,¹⁷ the societal cost of ReSTOR MF IOL is estimated to range from €3551 to €4052, whereas in the United States,²² the incremental cost of bilateral MF IOL implantation approximates $4000. In the Netherlands,¹⁹ the societal cost of ReSTOR MF IOLs is reported to be €3969, marginally lower than the €4123 estimated for monofocal lenses. This counterintuitive result can be explained by the adoption of a societal perspective in the Dutch cost model, which incorporated indirect costs such as productivity loss, informal caregiving, and long-term spectacle dependence. As MF IOLs substantially reduce reliance on corrective eyewear and facilitate faster visual rehabilitation, they generate lower downstream costs and thus yield a lower total societal burden. In Taiwan, China,²⁰ the incremental cost is reported to range between US $57 and US $58 per 1% improvement in spectacle independence, whereas in Australia,²⁴ the additional cost associated with MF IOLs is approximately AU $307. The monofocal IOLs, which serve as the baseline comparator in this analysis, are estimated to cost between €3989 and €5548 across Europe,¹⁷ contingent upon country-specific healthcare system structures, with a reported cost of €4123 in the Netherlands.¹⁹ In Australia,²⁴ monofocal lenses are reported to incur a relatively lower cost compared to MF IOLs.

Table 4.

Effectiveness Indexes and Outcome Statistics

	Main Effectiveness Indexes
Authors	Effectiveness Indexes	Measurement Methods	Costs	Outcomes
Smith AF et al.	Clinical success rate of each alternative	Retrospective clinical studies performed in the four countries	IOL and its implantation, IOL material, Nd:YAG laser therapy and its complications	Hydrophobic acrylic 175.29 French Cost/success (€) 184.85 Spanish Cost/success (€)348.8 Italian Cost/success (€) 230.6 German Cost/success (€)	PMMA 240.85 French Cost/success (€) 208.19 Spanish Cost/success (€) 418.88 Italian Cost/success (€) 201.41 German Cost/success (€)	Hydrophobic acrylic 326.35 French Cost/success (€) 426.78 Spanish Cost/success (€) 539.77 Italian Cost/success (€) 388.72 German Cost/success (€)	Silicone222.38 French Cost/success (€) 245.42 Spanish Cost/success (€)408.33 Italian Cost/success (€) 253.68 German Cost/success (€)
Maxwell WA et al.	WTP	An open-label multi-site US clinical trial	Reading glasses, distance glasses, bifocal glasses	MF IOL $11,670		CM-IOL $155
Lafuma A et al.	Prevalence rates of patients not needing spectacles after cataract surgery	Clinical trials	Implant surgery, IOLs, spectacles, visits to ophthalmologists and eye centers, transport, and time lost by patients	ReSTOR		Monofocal IOLs
				Societal perspective	€3551–€4052	Societal perspective	€3989–€5548
				SFs' perspective	€2150–€2524	SFs' perspective	€2324–€2610
Pineda R et al.	UCVA QALY	A prospective study Weighted by utility values to derive (Utility = 0.37 × UCVA +0.514)28	Surgery, additional costs for toric IOL and intraoperative limbal relaxing and peripheral corneal relaxing incision procedures, the total cost not reimbursed	Toric IOL −349 Incremental cost/QALY −393 Incremental cost/per patient with UCVA of 20/40 or better		Conventional monofocal IOL with intraoperative LRI/PCRI 3851 Incremental cost/QALY 3866 Incremental cost/per patient with UCVA of 20/40 or better
De Vries NE et al.	Spectacle independence rates VA	A randomized clinical trial	Spectacles, cataract surgery, IOLs, visits to ophthalmologists, optometrists, transport, and spectacle cleaning materials	Spectacle independence rates Lifetime discounted costs for the societyLifetime discounted costs for the NHS	ReSTOR86.0%€ 3,969€ 2,415	monofocal IOLs8.7%€ 4,123€ 2,555	Array-SA408.5%€ 5,326€ 2,556
Lin JC et al.	Vision-related QOL	25-item Visual Function Questionnaire (VFQ-25) developed by the National Eye Institute (NEI)	Spectacles, IOLs	Spectacle-independence rates Cost/spectacle-independence rate	Monofocal IOL, SA60AT31.80% —	Aspheric Multifocal IOL, ZM90089.50% 58.8 $/%	Aspheric Multifocal IOL, ReSTOR IQ90.90% 57.4 $/%
	Spectacle independence rates	The number of those who were without spectacles at near and far distances
Kristianslund O et al.	CDVA (logMAR) QALYVF-14	Published study29The utility values and a life expectancy30Visual Function-14 questionnaire	Equipment not used as a routine for both surgical techniques, a new IOL, surgical complications, additional operations and postoperative follow-up	Mean group difference (repositioning versus exchange)−281.20/−0.11 $/logMAR−1108/QALY $/QALY		95% CI of group difference [lower; upper][−281.20/−0.29; +281.20/0.08][−406/QALY; +1522/QALY]
Hu JQ et al.	QALY	Published papers31–33	IOLs and implantation, surgery and IOL exchange, ambulatory surgery fees, anesthesia fee, outpatient clinic fees and spectacles	Multifocal IOLsMonofocal IOLs	A total lifetime QALY17.66 16.95	The total cost$13,276.62 (societal perspective)$12,462.73 (health care perspective)$9,861.72 (societal perspective) $9,060.36 (health care perspective)	ICER (Multifocal IOLs vs. Monofocal IOLs)$4,804.63/QALY
Simons RWP et al.	HRQLUDVA/CDVADistance spectacle independence	Health Utilities Index Mark 3 (HUI3, Health Utilities Inc.)Published study34A questionnaire on spectacle use	Operating room time, IOL type, hospital daycare admissions, outpatient visits, complications, medication use, general practitioner visits, homecare, spectacles, travel, informal care, and productivity losses	Monofocal IOL from societal perspectiveToric IOL from societal perspective	Mean costs€ 2,796€ 3,319€ 3,203€ 3,456	Mean effects0.31/QALY 6-mo follow-up7.64/QALY lifetime extrapolation0.30/QALY 6-mo follow-up7.03/QALY lifetime extrapolation	ICER——InferiorInferior
	QALY	Determining the area under the curve of subsequent utility measurements (Utilities calculated by a multiplicative multi-attribute utility function.35)		Monofocal IOL from healthcare perspectiveToric IOL from healthcare perspective	€ 2,292€ 2,927	0.32/Spectacle independence0.33/Binocular UDVA 0.10 logMAR or better0.80/Spectacle independence0.56/Binocular UDVA 0.10 logMAR or better	——1310/patient2758/patient
Bala C et al.	QALY	The length of life multiplied by the utility weight36–37	DFT015 IOL and SN60WF IOL, cataract surgery (including surgeon's fee and hospital fee), and glasses (reading glasses, distance glasses, bifocal glasses, varifocal glasses)	DFT015 IOLSN60WF IOL	Total costAU $7528AU $7221	Total accrued lifetime QALY10.84510.684	ICER (DFT015 IOL vs SN60WF IOL)AU $1908/QALY
Ranno S et al.	VF-14CDVA	Visual Function-14 questionnaireSnellen chart and converted to a logarithm of the minimum angle of resolution (logMAR) visual acuity	Surgery, postoperative complications	CDVA (logMAR)VF-14ECD (cell/mm2)ICER	SF-IOL Group0.24 ± 0.1768 ± 181456 ± 525€3.30/ECD	AC-IOL Group0.32 ± 0.2661 ± 201341 ± 374	P value0.270.240.52
	ECD	Tomey EM-3000 noncontact specular microscope (Tomey, Nagoya, Aichi, Japan) by the semi-automated technique
HQO	QALY	Based on average utility values of cataract patients in Canada38	Total hospital costs, physician, and equipment/consumables fees	MultifocalMonofocalHydrophobic acrylicSilicone	Cost$755.46$55.46$755.46$815.27	Effect (QALY)8.9027798.8192438.9027798.902654	Cost per QALY$8,380Dominant
HTAIn	QoLQALY Vision-related QOL	Euroqol's EQ5D-5L questionnaireA separate primary study IND VFQ 33	Human Resource (HR) /labor, Non Consumables including Equipment, Furniture and fixtures, Infrastructure, Consumables including drugs and medicines and Overhead (Electricity and water bills, dietetics and laundry and maintenance charges)	Phacoemulsification with Foldable lens vs. SICS with rigid lens	ICER3862.79 INR/ QALY	Incremental Net Health Benefit:0.55 QALY	Incremental Net Monetary Benefit:63255.2 INR

From a utility standpoint, MF IOLs exhibit a significant improvement in QALYs across various regions. In France and Spain,¹⁷ the adoption of advanced MF IOL models, including AcrySof IQ Vivity, is associated with an estimated QALY gain of 0.16. In the United States,²² MF IOLs are associated with a substantial incremental QALY gain of 0.71 relative to monofocal lenses. Similarly, in Australia, MF IOLs yield an estimated QALY gain of 0.16.²⁴ By contrast, monofocal IOLs exhibit lower utility values, largely attributable to increased dependence on spectacles and the resultant lifestyle constraints.

From a cost-effectiveness perspective, MF IOLs demonstrate highly favorable ICERs compared with monofocal IOLs across multiple regions. In Europe,¹⁷ the ICERs for MF IOLs consistently remain well below €10,000 per QALY, regardless of whether the societal or payer perspective is applied, which is notably more cost-effective than monofocal IOLs in similar studies. In the United States,²² the ICER for MF IOLs is reported to be $4805 per QALY, which is substantially below the widely accepted threshold of $50,000 per QALY. The ICER of MF IOLs is estimated at $57 to $58 per percentage point improvement in spectacle independence in Taiwan, China, which highlights a clear benefit over monofocal IOLs, as these lenses generally do not provide similar improvements in spectacle independence. In Australia, the ICER for MF IOLs is reported to stand at AU $1908 per QALY, which is considerably lower than the threshold range of AU $45,000 to AU $75,000 typically used to define cost-effective interventions. Importantly, these cost-effectiveness models have accounted for the higher incidence of postoperative interventions associated with MF IOLs, such as laser enhancement and yttrium-aluminum-garnet (YAG) capsulotomy, which are more frequently required due to MF IOLs’ optical sensitivity to residual refractive error and posterior capsule opacification. For example, studies in Europe^17,19 modeled higher YAG rates for MF IOLs (20%) versus monofocal IOLs (14%), whereas US analyses²² incorporated the costs of laser enhancements. These adjustments ensure the ICER estimates reflect real-world resource utilization. By contrast, monofocal IOLs generally exhibit a less favorable cost-effectiveness profile over the long term. Although monofocal IOLs involve lower upfront costs, the cumulative expenses associated with spectacle dependence and the corresponding reduction in quality of life ultimately offset these savings, resulting in higher long-term costs and diminished utility compared with MF IOLs.

Toric Versus Monofocal IOLs

EEs of toric and monofocal IOLs demonstrate substantial cost disparities when comparing their short-term (first year) and long-term (lifetime) use. Toric IOLs are associated with significantly higher upfront and lifetime costs compared with their monofocal counterparts. In the United States,¹⁸ toric IOLs incur a first-year cost of $5739, whereas in the Netherlands,²³ this cost is estimated at €3203 (US $3864). Over a lifetime, toric IOLs in the United States incur a total cost of $7553, primarily attributed to elevated upfront surgical expenses. Nevertheless, these costs may be partially mitigated by reduced reliance on spectacles, potentially resulting in long-term economic benefits.¹⁸ In contrast, monofocal IOLs are associated with relatively lower upfront costs. In the United States, first-year costs vary from $4687 (without intraoperative refractive correction [IRC]) to $5635 (with IRC), whereas in the Netherlands, the equivalent cost stands at €2796 (US $3373). Over a lifetime, however, monofocal IOLs in the United States accumulate a total cost of $7587, rendering them comparable to their toric counterparts. This observation indicates that the upfront cost advantage of monofocal IOLs may be undermined over time by increased dependence on corrective visual aids, ultimately inflating long-term expenditures.

From a utility standpoint, toric IOLs deliver superior QALYs in lifetime analyses performed in the United States,¹⁸ achieving 10.20 QALYs. Conversely, short-term evaluations, including the Netherlands study,²³ report that toric IOLs generate merely 0.30 QALYs over 6 months. These utility benefits are primarily ascribed to diminished reliance on spectacles and enhanced uncorrected visual acuity (UCVA). Discrepancies among studies may be due to the method used to determine QALYs by Pineda et al. (see Table 4²⁸) leading in an overestimation of toric IOL effectiveness.³⁹

Cost-effectiveness analysis further differentiates the two IOL types. In the United States,¹⁸ toric IOLs demonstrate a markedly favorable ICER of $349 per QALY gained relative to monofocal IOLs without IRC, with lifetime cost reductions primarily driven by diminished dependence on visual aids. Conversely, in the Netherlands,²³ toric IOLs are reported to be less economically viable. They are associated with elevated costs and lower QALY outcomes compared with monofocal IOLs, with estimated costs of €1310 (US $1580) per spectacle-independent patient and €2758 (US $3327) per patient attaining binocular UCVA of 20/25 or better. The likelihood of cost-effectiveness for toric IOLs in the Netherlands is estimated to be minimal, ranging from 1% to 15% at willingness-to-pay thresholds of €2500 to €20,000 per QALY.

Rigid Versus Foldable IOLs

The EEs of rigid and foldable IOLs in cataract surgery, as reported in two independent studies, underscore substantial variations in cost-effectiveness across diverse clinical and resource settings. Material costs significantly differ, with foldable acrylic lenses (e.g. Acrysof at £79) costing nearly triple the price of rigid polymethyl methacrylate (PMMA) lenses (£30), as evidenced in a UK-based analysis,¹⁴ where surgical procedures with foldable lenses incurred an additional cost of £49 per patient compared with rigid lenses’ modest £6.25 surcharge for sutures. This cost differential extends to specialized instrumentation, as foldable IOLs require disposable injector systems, whereas ultrasound-dependent phacoemulsification techniques further escalate technical and equipment expenses. Despite these differences, postoperative follow-up costs remained comparable between the two groups, suggesting no added long-term economic burden from lens type.

The second study, an HTA conducted in India,²⁷ revealed a pronounced cost disparity (Indian Rupee INR] = 7000 vs. 5000–6000) mirroring national insurance reimbursement patterns that reflect higher resource utilization with foldable IOLs. Although phacoemulsification with foldable lenses showed superior visual outcomes potentially translating to QALY improvements, its ICER of INR 35,000 to 50,000 per QALY gained versus small-incision cataract surgery (SICS) with rigid lenses ultimately fails to offset the substantial upfront cost disadvantages. The combination of higher material costs (£79 vs. £30), specialized surgical requirements, and technology-intensive procedures reinforces the conclusion that rigid lenses remain more cost-effective despite foldable IOLs’ theoretical clinical advantages.

Hydrophobic Acrylic Versus Polymethylmethacrylate Versus Hydrophilic Acrylic Versus Silicone

A study comparing four types of IOLs (hydrophobic acrylic, PMMA, hydrophilic acrylic, and silicone) was conducted across four European countries.¹⁵ The finding revealed substantial variability in per-patient costs, spanning from €162.84 for hydrophobic acrylic lenses in France to €371.90 for hydrophilic acrylic lenses in Italy. Hydrophobic acrylic lenses consistently demonstrated superior cost-effectiveness across most countries, characterized by the lowest ICERs and reduced costs per successfully treated patient. For instance, in France, the cost per successful treatment for hydrophobic acrylic lenses was €175.29, which is significantly lower than the €326.35 recorded for hydrophilic acrylic lenses. Parallel trends were observed in Spain (€184.85 vs. €426.78), Italy (€348.80 vs. €539.77), and Germany (€201.41 for PMMA compared to €388.72) for hydrophilic acrylic lenses. The exceptional cost-effectiveness of hydrophobic acrylic IOLs was primarily attributed to their markedly reduced Nd:YAG laser intervention rates (7.1%) compared with the considerably higher rates observed with hydrophilic acrylic lenses (31.1%).

PMMA lenses demonstrated cost-effectiveness in select scenarios, particularly in Germany, where unregulated pricing policies favored their utilization. However, their elevated Nd:YAG-related costs limited their economic appeal in other contexts. Hydrophilic acrylic lenses were consistently the least cost-effective option, driven by their elevated Nd:YAG laser intervention rates (31.1%) and the resulting increase in associated costs. Silicone lenses exhibited moderate cost-effectiveness, typically ranking between hydrophobic acrylic and hydrophilic acrylic lenses in terms of economic efficiency.

IOLs Repositioning Versus IOLs Exchange

An EE of IOLs repositioning versus IOLs exchange for late in-the-bag dislocation underscored significant disparities in Norway. The analysis²¹ demonstrated that the IOL exchange incurred an additional cost of $281.20 per procedure, largely attributed to the expense of a new IOL and the frequent use of anterior vitrectomy. Despite the cost disparity, improvements in postoperative corrected distance visual acuity (CDVA) were comparable between the two groups. The difference in QALYs between the 2 interventions was minimal, with repositioning yielding a mean QALY gain of 0.19, discounted at 3.5%, and within the margin of error. From an economic standpoint, repositioning exhibited favorable ICERs, estimated at $–1108 per QALY gained, reflecting reduced costs and marginally enhanced utility. Depending on the assumptions regarding utility, the ICER ranged from $–406/QALY to $1522/QALY.

The need for IOL repositioning or exchange typically results from late in-the-bag dislocation, often due to zonular weakness caused by conditions such as pseudoexfoliation syndrome, high myopia, trauma, or prior ocular surgery. Although the Norway's study did not specify the types of IOLs dislocated, other studies have shown that toric and MF IOLs—particularly those with greater optical complexity and higher sensitivity to alignment—tend to require repositioning more frequently than monofocal lenses. Toric lenses demand precise rotational orientation; even small degrees of misalignment can significantly reduce their astigmatic correction and necessitate surgical realignment.⁴⁰ The MF IOLs are more sensitive to decentration or tilt, which may reduce visual quality and lead to earlier revision surgery, even in the absence of full dislocation.⁴¹

Scleral-Fixated IOLs Versus Anterior Chamber IOLs Implantation

An Italian study²⁵ revealed that the total costs for scleral-fixated IOL (SF-IOL) implantation were significantly higher, with an average expenditure of €1685 ± 189 per patient, compared to €992 ± 193 for anterior chamber IOL (AC-IOL) implantation. Despite the observed cost disparity, postoperative outcomes in terms of CDVA were found to be comparable between the two groups, with no statistically significant difference noted (SF-IOL = 0.24 ± 0.17 and AC-IOL = 0.32 ± 0.26). However, pronounced differences were observed in endothelial cell endothelial cell density (ECD) loss, with the AC-IOL group demonstrating significantly higher rates of ECD reduction (15.5%) compared to the SF-IOL group (3.5%, P = 0.004). From an incremental cost-effectiveness perspective, SF-IOL implantation incurred an additional cost of €693 per patient, effectively translating to €3.72 per endothelial cell preserved, with a net gain of 186 endothelial cells per procedure.

Heterogeneity

A range of studies has examined the heterogeneity in the cost-effectiveness of IOLs across diverse settings, using a variety of methodological approaches. Lafuma and Berdeaux (2008)¹⁷ applied a Markov model to evaluate the cost-effectiveness of ReSTOR versus monofocal IOLs across the same countries, illustrating significant cost savings with ReSTOR (€815–2164 in societal savings) in all the nations analyzed. De Vries et al. (2010)¹⁹ used propensity score matching and linear regression techniques in the Netherlands, demonstrating ReSTOR's superior spectacle independence (86.4%) and cost savings (€315 societal and €140 payer) relative to monofocal and Array-SA40 lenses. Hu et al. (2019)²² and Bala et al. (2022)²⁴ performed one-way sensitivity analyses, revealing that MF IOLs lost cost-effectiveness beyond the age of 92 years or in patients with high spectacle dependence, with the cost of the IOL being identified as the most influential parameter. Kristianslund et al. (2019)²¹ examined postoperative visual acuity and surgical time adjustments, highlighting uncertainty in ICERs for IOL repositioning (ranging from −406 to +1522/QALY) and the potential for cost savings due to reduced surgical time. These findings underscore the necessity of tailoring the IOL selection according to both patient-specific factors and the characteristics of the healthcare system.

Uncertainty

A total of eight studies used statistical and sensitivity analyses to account for uncertainty. Maxwell et al. (2008),¹⁶ Pineda et al. (2010),¹⁸ Lafuma and Berdeaux (2008),¹⁷ De Vries et al. (2010),¹⁹ Hu et al. (2019),²² Simons et al. (2019),²³ Bala et al. (2022),²⁴ and Kristianslund et al. (2019)²¹ utilized a range of analytical approaches, including probabilistic sensitivity analysis (PSA), deterministic sensitivity analysis (DSA), and scenario-based modeling. The key determinants affecting cost-effectiveness outcomes encompassed willingness-to-pay (WTP) thresholds, spectacle independence rates, complication-associated costs, and applied discount rates.

PSA was implemented in five studies, with Maxwell et al. (2008)¹⁶ and Hu et al. (2019)²² consistently demonstrating the cost-effectiveness of MF IOLs across nearly all simulations (99.9% at a $50,000/QALY threshold). Bala et al. (2022)²⁴ further substantiated the cost-effectiveness of AcrySof IQ Vivity IOLs, reporting a 100% probability at a WTP threshold exceeding $15,000/QALY. By contrast, Simons et al. (2019)²³ identified toric IOLs as economically suboptimal in the short term, with a mere 1% to 15% probability of cost-effectiveness at a €20,000/QALY threshold.

DSA across studies underscored the susceptibility of cost-effectiveness outcomes to variations in spectacle independence rates, IOL costs, and discount rates. For instance, Lafuma and Berdeaux (2008)¹⁷ demonstrated ReSTOR's economic dominance at spectacle independence rates of at least 20%, whereas De Vries et al. (2010)¹⁹ corroborated its long-term cost-saving potential under discount rate variations ranging from 0% to 4%. Kristianslund et al. (2019)²¹ highlighted the indirect economic advantages associated with reduced surgical time.

Scenario-based analyses conducted by Hu et al. (2019)²² and Bala et al. (2022)²⁴ examined variations in patient age, time horizons, and spectacle dependence, consistently reinforcing the cost-effectiveness of advanced IOLs across a range of clinical and economic contexts. These findings underscore the robustness of the applied models and further affirm the economic viability of MF and toric IOLs across diverse healthcare settings.

Fundings

We found that studies conducted before 2010 were mostly sponsored by the same ophthalmic device company. The control group in these studies is usually a monofocal IOL, compared with a multifocal or modified IOL developed and sold by the company. Since then, national authorities have sponsored research, and the research objects have been expanded from the original comparison of monofocal and MF IOLs to toric IOLs, comparison of different lens materials, and comparison of the cost-effectiveness of different lens implantation methods.

Discussion

This systematic review synthesizes evidence from 14 health EEs of IOLs across diverse healthcare systems, offering critical insights into the cost-effectiveness of advanced IOL technologies for cataract management. Our findings underscore the economic superiority of MF IOLs over monofocal counterparts in patients prioritizing spectacle independence, with ICERs consistently below established WTP thresholds (e.g. $50,000/QALY in the United States and €20,000/QALY in Europe). However, the economic viability of IOLs is contingent upon clinical context, patient-specific factors, and regional healthcare financing structures, necessitating a nuanced interpretation of these results.

The MF IOLs demonstrated robust cost-effectiveness across high-income settings, driven by reduced spectacle dependence (86.0–90.9% vs. 8.5–31.8% for monofocal IOLs) and sustained QALY gains (ΔQALY = 0.16–0.71). Notably, hydrophobic acrylic IOLs emerged as the most cost-effective material due to lower Nd:YAG laser intervention rates (7.1% vs. 31.1% for hydrophilic acrylic), aligning with prior studies emphasizing material durability and postoperative complication rates.^15,42 Toric IOLs exhibited divergent outcomes: whereas US models showed long-term cost savings ($349/QALY),¹⁸ Dutch analyses reported limited cost-effectiveness (1–15% probability at €20,000/QALY),²³ likely reflecting differences in healthcare reimbursement policies and patient valuation of UCVA. Such discrepancies highlight the importance of incorporating local cost structures and patient preferences into economic models.

Methodologically, Markov models dominated included studies, enabling long-term cost-utility projections. However, critical limitations persisted. First, few models accounted for IOL explantation or secondary procedures (e.g. excimer laser adjustments), potentially underestimating lifetime costs.²⁴ Notably, although the overall explantation rate of IOLs remains low, MF IOLs are consistently associated with a higher likelihood of removal compared with monofocal lenses due to visual disturbances, such as glare, halos, and reduced contrast sensitivity. Reported MF IOL explantation rates range from 0.8% to 3%,⁴² compared to approximately 0.2% for monofocal IOLs.⁴³ Primary indications for MF IOL removal include dysphotopsia and failure to neuroadapt,⁴⁴ whereas monofocal explantation is more commonly linked to mechanical or refractive complications.⁴³ Although visual outcomes after exchange are generally favorable, surgical risks and added costs are non-trivial. Second, reliance on short-term utility estimates (e.g. 6-month follow-ups)²³ may inadequately capture longitudinal QALY trajectories. Third, heterogeneity in outcome measures (e.g. visual acuity versus EQ-5D-5L) complicates cross-study comparability. These gaps underscore the need for standardized, patient-centered metrics that integrate both clinical (e.g. CDVA) and psychosocial outcomes (e.g. spectacle-related stigma).^28,45 Although rare, downstream events such as IOL explantation due to visual disturbances—more common with multifocal lenses—introduce additional costs and risks that are often omitted from economic models. Incorporating the probability and consequences of such events would strengthen the validity of future cost-effectiveness evaluations.

The economic dominance of MF IOLs in high-income settings must be contextualized within broader healthcare priorities. In resource-constrained systems, rigid PMMA lenses remain pragmatic for large-scale cataract programs despite inferior visual outcomes,²⁷ whereas foldable acrylic lenses may justify higher costs in contexts valuing postoperative quality of life. Notably, China's volume-based procurement policy⁸ and India's HTAs²⁷ exemplify efforts to balance technological advancement with affordability, although persistent disparities in LMIC research output (only 3 of 14 studies from LMICs) hinder evidence-based policymaking. Future evaluations should adopt societal perspectives that capture indirect costs (e.g. productivity losses) and non-medical burdens (e.g. caregiver time), particularly in aging populations where cataracts disproportionately affect economic productivity.^3,46

Although this review adhered to PRISMA and CHEERS guidelines, several constraints merit acknowledgment. First, industry-sponsored studies dominated early literature (pre-2010), raising potential bias risks despite rigorous quality assessments. Second, the exclusion of non-English/Chinese literature may overlook region-specific economic dynamics. Third, the lack of real-world cost data (e.g. patient out-of-pocket expenditures for spectacles) limits generalizability to decentralized health systems. Fourth, comparative studies evaluating foldable versus rigid IOLs often relied on earlier data when extracapsular cataract extraction (ECCE) was more common and typically performed by highly experienced surgeons. In contemporary high-income countries, however, most surgeons are trained predominantly in phacoemulsification, and may lack the operative fluency for ECCE, resulting in longer surgical time, increased complication risks, and greater intraoperative resource use when rigid IOLs are used. These indirect costs—although infrequently quantified—may lead to underestimation of the true economic burden associated with rigid IOLs in such settings^14,47 By contrast, in lower-income countries where ECCE remains standard practice and surgical expertise is maintained, these procedural inefficiencies may not apply, underscoring the need for geographic contextualization when interpreting legacy cost-effectiveness analyses.⁴⁸

To address these gaps, future research should integrate real-world evidence by leveraging registry data and longitudinal cohorts to validate model assumptions, including spectacle replacement frequency, whereas also capturing unmeasured confounders such as socioeconomic status. Moreover, incorporating patient-centered valuation through discrete choice experiments could provide a more nuanced understanding of WTP for advanced IOL features, particularly in LMICs where cultural perceptions of visual impairment may differ.^32,46 In parallel, lifecycle cost analyses examining the environmental and economic impacts of IOL procurement, sterilization, and disposal would offer valuable insights for promoting sustainable healthcare practices.⁸ Finally, equity-focused modeling should be prioritized to ensure that cost-effectiveness analyses account for vulnerable subgroups, such as patients with low endothelial cell density, thereby fostering more equitable access to premium IOL technologies.²⁵

Conclusions

This review consolidates a growing evidence base supporting the cost-effectiveness of IOLs in cataract surgery, whereas emphasizing the critical interplay between technological innovation, healthcare financing, and patient-centered outcomes. As global cataract burdens escalate, policymakers must prioritize context-specific economic evaluations that reconcile clinical efficacy with affordability—ensuring that advancements in ophthalmic care translate equitably across diverse health systems.