George O. Waring IV, MD, FACS’s, “Presbyopia’s Coming of Age” blog focuses on surgical and technological innovations in presbyopia correction. Waring is founder and medical director of Waring Vision Institute in Mt. Pleasant, South Carolina.

BLOG: Why my practice has evolved toward a personalized vision approach

Although we have enjoyed great success with bilateral extended depth of focus IOLs in patients who want spectacle independence after cataract surgery, I am increasingly opting for a personalized vision combination of the Tecnis Symfony EDOF and a low-add multifocal for the majority of cases.

The advantage of the Symfony lens (Johnson & Johnson Vision) is that it offers a high quality of vision that, in my experience, is unsurpassed among current presbyopia-correcting IOLs. The quality of vision is due to the active correction of chromatic aberration, compensation for the cornea’s spherical aberration, full diffractive optic and other properties of the Tecnis acrylic lens material. The EDOF lens also has the advantage of a continuous range of vision that feels natural to patients.

Where it is slightly lacking, however, is in near vision for very small print. In the past, when talking to patients about bilateral EDOF lenses, we talked about offering maximum visual quality and elongating the depth of focus up to a “social reading” circumstance. I explained that they would be able to do most things, most of the time, without glasses, but might need readers for fine print or prolonged reading. For the most part, patients understood and accepted that, and we often observed outstanding uncorrected near vision with bilateral EDOF lenses.

However, this compromise sometimes made for a more challenging comanagement relationship. I found that referring optometrists were sometimes disappointed with the Jaeger acuity they measured, even if the patient was spectacle independent the majority of the time. It required a different way of thinking about near vision that didn’t always translate once the patient left the surgery center.

With personalized vision — implanting a Symfony EDOF lens in the dominant eye and a low-add (+3.25) diffractive bifocal in the nondominant eye — I’ve found that we can consistently cover the near range in a more robust fashion, while still maintaining excellent distance vision and stereoacuity. In a Canadian study, for example, 94% of subjects had bilateral uncorrected near of 20/25 or better with this combination of lenses. At the 2019 American Society of Cataract and Refractive Surgery meeting, Mark Kontos reported significantly better near with the combination than with bilateral EDOF lenses, and Frank Bucci noted that the personalized vision combination led to better intermediate and distance vision than bilateral Tecnis multifocal lenses (with either +4.00 or +3.25).

In my clinical experience, patients love the seamless vision from near to far with the personalized vision combination of an EDOF/+3.25 multifocal, and their comanaging optometrists are happy, too. As a result, this has become one of our primary strategies in refractive cataract surgery.


Black S. A clinical assessment of visual performance of combining the Tecnis Symfony extended range of vision IOL (ZXR). Presented at: American Society of Cataract and Refractive Surgery annual meeting; May 3-7, 2019; San Diego.

Bucci FA Jr. A comparison using multiple regression analysis of predictors of patient satisfaction with an EDOF/+3.25 versus bilateral +3.25 versus bilateral +4.00 diffractive multifocal IOLs at the time of cataract surgery. Presented at: American Society of Cataract and Refractive Surgery annual meeting; May 3-7, 2019; San Diego.

Kontos MA. Analysis of patient satisfaction, visual, and functional outcomes after bilateral versus paired extended range of vision/+325 multifocal IOL implantation. Presented at: American Society of Cataract and Refractive Surgery annual meeting; May 3-7, 2019; San Diego.


Disclosure: Waring reports he is a consultant for Johnson & Johnson Vision and a member of the Johnson & Johnson Vision optics advisory board.