One Australian eye surgeon believes many of the 250,000 people who have cataract surgery each year are not getting the results they deserve. He’s urging the industry to take a wider view to ensure patients are getting the best outcomes.
Dr Rahul Chakrabarti has a challenge for many of his ophthalmic colleagues.
And it’s potentially a controversial one.
He’s urging a substantial portion of fellow surgeons around Australia – a figure he believes is about one-third of the sector – to end their blinkered over-use of monofocal intraocular lenses (IOL) in cataract surgery and instead offer patients more and better options, including the quality outcomes available in extended depth of focus (EDOF) lenses.
In fact, he goes further.
Dr Chakrabarti believes EDOFs should now be considered the standard of care in ophthalmology, that monofocals should only be used in a small number of specific situations, and that surgeons who don’t provide options beyond monofocal IOLs may be straying into medico-legal issues.
Now let’s make one thing clear: there is no official standard of care designation around which IOLs a surgeon should use. But it appears monofocals have been used for so many years, and have proven their cost-effectiveness, particularly in public health settings, that they have become the default ‘go-to’ for many.
But as Dr Chakrabarti and others point out, that has been overtaken by significant advances in IOL technology over the last decade, including the rise of the EDOF as a powerful and often preferred alternative.
A momentum driven not only by the industry but also growing patient expectations.
Dr Chakrabarti is a general ophthalmologist in Melbourne and only recently stepped down as director of training at The Royal Victoria Eye and Ear Hospital. He also has consultancy roles at a number of private practices around the state.
Common conditions treated include cataracts, diabetic eye disease, age related macular degeneration and retinal vein occlusions, and glaucoma.
He’s reasonably young and has a passion not only for optics but also the constantly changing technology in the sector.
“When I started training as an eye surgeon in 2013 we only had monofocal lenses, and in the public health setting there was a very high threshold for toric lenses,” he says.
“Initially, the threshold in Victoria was 2.50 D of astigmatism for a public patient to have a toric lens implanted. And over the years, I think with evidence, as well as looking at cost effectiveness, the toric thresholds have come down.”
That heavy use of monofocal IOLs continued when he entered private practice six years ago.
“But I think the landscape has changed dramatically, even over the last 10 years,” he says.
“I’m finding I’m putting in fewer monofocal lenses, and in the majority I have put in what we call enhanced focus lenses (EDOFs), with about 20% of my patients having trifocal lenses.”
Dr Chakrabarti often uses Johnson & Johnson’s PureSee IOL and says most of his patients have achieved excellent long, intermediate and even reading vision.
That choice is based on discussions with his patients but also the mounting evidence backing the evolution of IOLs and technological advances in EDOFs, especially in the past few years.
“We now have a new range of lenses which offer much better functional near vision without compromising the patient’s distance vision, and I think that’s what I’m passionate about, and most of my patients similarly, over the last four years, as I’ve transitioned to majority EDOF IOLs, almost as a routine.”
He still uses monofocal IOLs in about 10-15% of cases.
“That might be in patients who have fluctuating retinal conditions or other ocular pathology that interferes with their eyes’ ability to have excellent vision.”
But in the absence of those conditions, Dr Chakrabarti believes that surgeons putting in a monofocal lens are using a “somewhat inferior option compared to the enhanced depth of focus”.
Which is why he is disappointed that so many of his colleagues have not yet widened their own view beyond the traditional, tried and true monofocal IOLs.
“We have a luxury of choice in Australia in particular, and I know that we have access to many different types of lenses in our practices, so it might be the level of comfort that a surgeon has in a particular type of technology,” he says.
“They may have previously had negative experiences with certain types of lenses, which then makes them reluctant to consider that as an option.”
Those “negative experiences” often involved issues with night vision, including halos and glare. But since around 2020, many of the EDOFs have evolved to effectively address those problems.
“I’m more open minded. I think the companies and the industry are moving more rapidly in terms of their design and also auditing the outcomes, both industry outcomes but also real-world outcomes from clinicians.”
Public patients getting ‘inferior option’
Dr Chakrabarti believes that it’s largely the patients in the public health setting receiving the “somewhat inferior option” of a monofocal IOL, when another lenses might mean better outcomes.
“The majority of public hospitals will have monofocal lenses,” he says. “Very few, such as The Eye and Ear Hospital, actually have a range of EDOFs.”
That largely comes down to cost, with EDOFs and other multifocal IOLs costing a little more than their monofocal counterparts.
Dr Chakrabarti believes that’s wrong on a number of levels.
“Public patients should have access to the best technologies.
“Even if that means having a flexible funding model where patients are offered this option and are aware of maybe an additional cost, that should at least be open to discussion.”
But he believes it’s also short-sighted.
“There’s a cost to the entire system in not having those options. Yes, a product might be more expensive, but there’s also a cost in patients going to their optometrist to have glasses updated.”
And a potential impact on the value of training as well.
“From a surgical education perspective, offering enhanced depth of focus lenses to public patients in Australia, beyond standard monofocal lenses, is crucial for advancing ophthalmic training for the modern eye surgeon,” he says.
“Limiting public access to monofocals restricts residents’ exposure to diverse intraocular lens technologies and their nuanced clinical planning, discussion, counselling and implantation techniques.”
He believes that helps create a two-tiered system where future surgeons in the public sector are less prepared for the full spectrum of patient needs and technological advancements found in private practice.
“Broadening access to EDOF lenses in public hospitals ensures comprehensive surgical experience, fostering well-rounded, adaptable ophthalmologists equipped to deliver optimal visual outcomes for patients with all visual demands.”
So Dr Chakrabarti is essentially saying the jury is in, the evolution and efficacy of EDOFs have been proven, and colleagues not offering them, at least as an option, are guilty of not giving their patients the best quality of care.
But what do the studies say.
Firstly, they appear to back his contention that EDOFs are clinically better than monofocals.
One study, published in the Journal of Cataract and Refractive Surgery, asked if there was enough scientific evidence to “confirm the clinical superiority of enhanced monofocal over conventional monofocal IOLs”.
Researchers in the 2024 study combed the results of three reviews and 66 articles.
They concluded that, yes, in the debate over what should constitute standard of care (SoC), enhanced monofocals had demonstrated clinical superiority.
“The first condition for establishing the use of enhanced monofocal IOLs as SoC in cataract surgery is accomplished,” they said.
That view was supported in a number of other studies, prompting the European Society of Cataract and Refractive Surgeons to promote the use of EDOFs and multifocal IOLs in recent guidelines.
But while the research in the Journal of Cataract and Refractive Surgery said EDOFs had met the “first condition” in resolving the debate, it suggested there was one area where the jury was still out, especially in public healthcare.
“Cost-effectiveness studies are still needed and highly recommended to demonstrate that the clinical benefit obtained with enhanced monofocal IOLs is greater than the cost increase compared with conventional monofocal IOLs.”
That very question was examined in another study by Italy’s National Healthcare Service.
Researchers developed a cost-utility model incorporating both healthcare and non-healthcare costs, using data from a socio-economic questionnaire administered at three clinical centres in Italy.
They investigated aspects related to the quality-of-life of patients and the social and economic impact after cataract surgery, including the cost of follow-up visits and treatments, the costs of paid support for the person, and impacts on productivity.
The study concluded that the monofocal IOL was indeed more cost-effective when considering its “direct healthcare costs” within the Italian system, “making the standard option more favourable in terms of immediate healthcare expenditures”.
But the enhanced monofocal IOL saved costs in other areas, “reducing the overall economic burden by lowering both direct and indirect costs while maintaining patients’ quality-of-life”.
Researchers said “these broader benefits, such as reduced dependency on corrective measures, visits and exams, formal and informal assistance, highlight its value to society”.
“This contrast underscores the importance of a holistic approach to healthcare decision-making, where long-term societal savings and patient benefits are considered alongside short-term healthcare costs.”
That holistic approach, the greater consideration of patients’ needs and the offering of more effective options, is at the heart of Dr Chakrabarti’s passionate advocacy – it’s not necessarily that EDOFs alone should be the new standard of care but that they should be part of the conversation for each and every patient.
‘Paradigm shift’ in patient options
It’s a sentiment Western Australia surgeon Associate Professor Rob Paul agrees with.
“What should be the standard of care is that any cataract surgeon or refractive surgeon should be offering an EDOF lens as a first-line treatment in patients who are suitable,” he says.
The medical director of WA Laser Eye Centre, consultant ophthalmologist and associate professor at the University of WA optometry school was an early adopter of multifocal IOLs almost 20 years ago, even though they often offered “good reading vision but pretty ordinary distance vision and absolutely no intermediate vision”.
Like Dr Chakrabarti and many others interviewed by Insight, he has been impressed with the evolution of EDOFs and the quality they provide compared with traditional monofocal IOLs.
“With the advent of EDOFs there’s been a real paradigm shift in terms of what we can offer patients,” he says.
“For those wanting more spectacle independence, I usually put an extended depth of focus lens in the dominant eye and a true multifocal in the non-dominant eye, because it reduces the glare, the halos and the dysphotopsias – that’s my preferred option now.”
Similar to his colleague in Victoria, A/Prof Paul is not dismissing monofocal IOLs out of hand.
He too uses them in 10-20% of cases.
“Monofocal lenses are ideal in patients who are, say, high myopes or myopes that are actually using a monovision set-up where we set one eye for distance and one eye for near – that’s an ideal situation.”
He’s also happy to recommend them for certain patients prioritising distance vision, including pilots, and target and clay shooters.
“When you give them the option, they say, ‘Oh, look, mate, just set both eyes for distance or give me a bit of monovision, and I’ll be happy with that.”
But he too is concerned at the number of patients, and particularly those going through the public system, who are not offered EDOFs or other presbyopia-correcting lenses as part of their surgery and treatment plans.
That’s despite companies closing the gap on the cost of an EDOF compared with a monofocal IOL.
“In the public system, I think the companies have been quite good,” he says. “They’ve brought it down to maybe a $200 difference, so it’s quite acceptable.”
He believes bureaucracy is also to blame, “because they have to change the itemisation of the numbers”.
What that adds up to is a sizeable portion of the 250,000 Australians who receive cataract surgery every year being implanted with potentially a “somewhat inferior option”. And it’s an option that’s not easy to reverse.
“It’s wrong,” says A/Prof Paul, “because it should be a fair and equitable system for everybody, but it’s not.”
Many of those patients are becoming increasingly aware that they are missing the train of that “paradigm shift”; that the evolution of EDOF technology has opened what he calls “a whole new world” – from which they are excluded.
“There was a market survey done that actually showed that one in three patients are expecting to be spectacle independent after cataract surgery,” he says.
“When they simulated presbyopic correcting lens vision to them with the technology that they use, 90% of people said, ‘look, I want that’ – 50% wanted EDOFs and 50% wanted multifocal.
“So the patients are now more demanding and more informed than they ever were five years ago.”
In fact, A/Prof Paul spends a fair bit of his chair time explaining to some patients why they are getting a monofocal when an EDOF is not the best choice, including cases of significant corneal or macular disease.
“This is a reverse of what used to occur in the early EDOF/trifocal era,” he says.
Dr Chakrabarti is also noticing this demand pull, to go with the supply push of frequent new products from various companies.
And that’s what has him worried.
Insight suggests to him that some patients, armed with knowledge about EDOFs and the advances in the technology, might simply vote with their feet and go to another ophthalmologist offering more and better options.
“I’ll flip it the other way,” he says.
“I’ll say, from a medical-legal perspective, we have an obligation as modern and safe clinicians to provide evidence-based information to our patients, to have the conversation and guide them in making an informed decision.
“If you don’t provide them the range of options, even though you might not think a particular lens is a safe option for them, then I think that is in some ways negligent.”
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