Picking the Lens: Monofocal, Multifocal, Toric, and What Medicare Pays

The intraocular lens, or IOL, is a permanent plastic or silicone implant that replaces the natural cloudy lens during cataract surgery. The American Society of Cataract and Refractive Surgery, known as ASCRS, recognizes four main IOL categories: standard monofocal, toric for astigmatism, multifocal or extended-depth-of-focus for reduced glasses dependence, and accommodating lenses that flex like a natural lens. Choosing the right lens is the most consequential decision the patient makes during the entire process, because the IOL stays in the eye for life.

The standard monofocal IOL is fully covered by Medicare Part B and almost all commercial insurance. A monofocal lens is set to one focal distance, usually far vision, which means the patient will still need reading glasses for books, menus, and phone screens after surgery. About 75 percent of US cataract patients choose monofocal because of the cost and the predictability. The AAO notes that monofocal lenses produce the sharpest contrast sensitivity and the lowest rate of glare or halo complaints in the first year after surgery.

The toric IOL corrects pre-existing astigmatism, meaning a non-spherical curve of the cornea. Medicare covers the surgery itself but does not cover the additional toric upgrade fee, which usually runs 1,200 to 2,000 dollars per eye. A toric lens is the right choice for any patient whose corneal astigmatism exceeds 1.25 diopters on biometry, because correcting astigmatism with eyeglasses after a monofocal implant is less precise than correcting it inside the eye. ASCRS guidelines recommend toric implants for about 30 percent of cataract patients.

Multifocal IOLs, such as the PanOptix, Tecnis Synergy, and Vivity, attempt to provide near, intermediate, and distance vision without reading glasses. They use concentric rings or extended-depth-of-focus optics to split light among multiple focal points. The out-of-pocket cost ranges from 2,500 to 4,000 dollars per eye on top of the standard surgical fee Medicare already covers. The tradeoff is glare and halos at night, particularly while driving, in about 10 to 20 percent of patients. ASCRS recommends multifocal lenses for patients who strongly want glasses independence and who do not drive at night for work. Sources: aao.org/eye-health/treatments/intraocular-lenses-iols, ascrs.org/patients/iol-options, and medicare.gov/coverage/cataract-surgery.