Cataract: Changing mindsets
Summer 2025
Ophthalmology is constantly innovating and evolving to new and unmet needs in the clinic and OR. EyeWorld asked members of its Cataract Editorial Board and members of the ASCRS Cataract Clinical Committee to weigh in on: If I could ask industry to produce one new product, this is what it would be and why.
Alice Epitropoulos, MD
Dr. Epitropoulos suggested the need for a next-generation adaptive multifocal IOL with smart light filtering.
While the newest trifocal technology has greatly improved the range of vision for cataract patients with less dysphotopsias, Dr. Epitropoulos said that challenges still exist—particularly with visual disturbances like halos, especially in low-light conditions.
An IOL that could automatically adjust its focus based on the lighting conditions would be a major breakthrough, she said. “A smart multifocal IOL that integrates a light-sensing technology that dynamically adjusts the lens power based on ambient light, optimizing near, intermediate, and distance vision in real time would be the holy grail.”
For example, Dr. Epitropoulos said, in bright light, it could provide sharper distance vision; in dim light, it could shift to improve near and intermediate focus. The lens could also feature advanced filtering to reduce glare and halos without affecting contrast sensitivity, making it ideal for nighttime driving.
“This product would address two of the main concerns that patients have with multifocal IOLs—visual disturbances and adaptability in changing lighting environments—offering them a seamless and natural visual experience post-surgery. It would also give surgeons more flexibility in offering customized solutions to patients based on their lifestyle and needs.”
Huck Holz, MD
Dr. Holz would like to see a local motor neuron blockade system to inhibit movement during surgery. Most surgeons operate under topical MAC, and it is not unusual for people to become disinhibited during surgery and move their eyes, body, or both, Dr. Holz said. “This is dangerous for patients and not only frustrating but extremely stressful for surgeons. It seems to be the case that the patients who have incomplete zonule support also have frontal cortex disinhibition and are therefore prone to movement under local MAC,” he said. “In addition, soon enough we will enter the era of robotic surgery. I am confident in this because we only have two opposable thumbs, whereas machines may have many. This type of equipment will undoubtedly require extremely stable patients.”
Dr. Holz would like to see the development of a local motor neuron blockade system to inhibit movement while in surgery and make surgery safer for patients. “This could be used to inhibit movement of the eye and orbicularis,” he said.
Dr. Holz added that there are a few ways to do this. He suggested electrical and magnetic techniques, noting transcranial magnetic stimulation, which can be used to temporarily disrupt motor neuron activity in a targeted area of the brain. Or nerve blocks with electrical stimulation could be used, and some devices use electrical impulses to interfere with motor neuron signaling.
“Development of such a product would make surgery far safer for patients and less stressful for surgeons,” he said.
Nicole Fram, MD
Dr. Fram suggested new products she’d like to see in the cataract refractive and cornea fields.
“My request in the cataract refractive world would be a single-piece and 3-piece, 7-mm optic with a low index of refraction and an edge design that would reduce dysphotopsia,” she said. “I would also have this lens be adjustable with the ability to wavefront match corneal higher order aberrations.”
Her request in the cornea world would be for an emphasis on limbal stem cell restoration. “This is an ignored area that is critical to success with any transplantation surgery,” she said.
Ashraf Ahmad, MD
Dr. Ahmad is looking for an adjustable extended depth of focus (EDOF) and multifocal IOL.
He said that this product would be useful because the ability to fine tune the lens power or focal range post-implantation would be a game changer. “It would allow for customized visual outcomes, reducing the need for enhancements and improving patient satisfaction—especially for those with challenging or borderline preop measurements.”
Dagny Zhu, MD
Dr. Zhu had several suggestions on products that she’d like to see from industry, based on complaints she gets in her practice.
- A single-piece, hydrophobic acrylic IOL with a near zero chance of causing temporal negative (and secondarily positive/edge glare) dysphotopsias. She said increasing the optic size to 7 mm and reducing the index of refraction (and increasing Abbe value) would help to achieve this.
- A low-cost, small footprint laser that can obliterate visually significant vitreous floaters more efficiently and safely than a YAG and less invasively than a pars plana vitrectomy.
“Negative dysphotopsia and floaters are the top two complaints in my premium IOL practice (more annoying than positive dysphotopsias, which are expected and limited by current optical design),” she said, adding that she thinks these are two issues that can be fixed.
Robert Weinstock, MD
Dr. Weinstock is looking for a one-stop shop machine to help make his clinic more efficient.
“From the clinic perspective, we’re increasingly in a situation where there’s less staff available, but there are more and more patients we need to see,” he said. “Clinic efficiency needs to catch up with what we’ve been able to accomplish in the operating room with efficiency.”
In the era of premium cataract surgery and trying to get patients out of glasses, we need a lot more information preoperatively, he added.
Industry has developed machines to help analyze the anterior segment and the posterior segment, Dr. Weinstock said, but this involves a lot of human power in running people through different machines. You also need space for these machines in the practice, they’re expensive, and you need staff to operate them. “Every time you need to get a test on a patient preoperatively, you have to move the patient from one machine to another,” he said.
Dr. Weinstock said that what would be great is a single machine for cataract surgeons to help their clinic throughput. In an ideal world, one machine would have many functionalities for testing. He would like one machine that did a slit lamp photo, epithelial mapping, corneal analysis (hopefully with two different technologies like Placido and ray tracing), as well as cataract density imaging to help show patients the density of the cataract, an internal aberration of the eye with wavefront scanning of the optical system, OCT biometry, and a retina quality image of the posterior segment to give a good view of the macula. If it did a widefield photo of the retina, that would be a bonus, Dr. Weinstock said.
“If we had all of that as a one-stop shop machine, that would be a tremendous improvement to efficiency in the clinic and allow us to see more patients and do more surgeries,” he said. From an industry perspective, Dr. Weinstock said it may not be desirable to have one machine doing everything, but he suggested that this one machine could come with a heftier price tag since it would be accomplishing many tests. The doctor would have everything they needed by the time they saw the patient. A technology like this could cut down on appointment times.
Adding his thoughts from a surgery perspective of new technology he would like, Dr. Weinstock said, “I don’t think we’ve cracked the code on the perfect IOL.”
Every generation of multifocal optics are good but not perfect, he said. “We need to continue to innovate and come up with optic designs that have less side effects and dysphotopsias, that provide the full freedom from glasses that patients want, and that we can use in more patients even if they have pathology,” he said.
About the physicians
Ashraf Ahmad, MD
Cataract, Cornea & Refractive Surgery
Harvard Eye Associates
Laguna Hills, California
Alice Epitropoulos, MD
Central Ohio Eye & Plastic Surgery
The Eye Center
Columbus, Ohio
Nicole Fram, MD
Advanced Vision Care
Los Angeles, California
Huck Holz, MD
Kaiser Permanente
Santa Clara, California
Robert Weinstock, MD
Medical Director
Eye Institute of West Florida
Regional Medical Director
EyeCare Partners
Largo, Florida
Dagny Zhu, MD
Medical Director and Partner
NVISION Eye Centers
Rowland Heights, California
Relevant disclosures
Ahmad: Bausch + Lomb
Epitropoulos: None
Fram: None
Holz: None
Weinstock: Consultant to most ophthalmic companies
Zhu: Alcon, Bausch + Lomb, Johnson & Johnson Vision
Contact
Ahmad: aahmad@harvardeye.com
Epitropoulos: eyesmd33@gmail.com
Fram: nicfram@yahoo.com
Holz: drhuckholz@gmail.com
Weinstock: rjweinstock@yahoo.com
Zhu: dagny.zhu@gmail.com
