Current Management of Presbyopia – Patient Selection

Based on Dr Mohamad Rosman’s presentation to eye doctors in Jakarta

On 16 August 2026, Dr Mohamad Rosman participated as an invited speaker at Beyond 20/20: Mastering Presbyopia Management in Cataract Surgery, an educational session for eye doctors in Jakarta.

His presentation, titled Current Management of Presbyopia: Patient Selection, covered the available approaches to presbyopia and the factors considered when selecting an option.

The presentation related to presbyopia, LASIK, ICL and cataract surgery.

What Options Are Available for Presbyopia?

Dr Rosman grouped the available approaches into five categories:

• Spectacles
• Multifocal contact lenses
• Prescription eye drops
• Laser refractive surgery
• Lens-based refractive surgery

Laser refractive procedures discussed in the presentation included:

• LASIK
• SMILE
• Surface ablation

Lens-based procedures included:

• Phakic intraocular lenses
• Intraocular lenses used during cataract surgery

The choice depends on factors such as whether a cataract is present, the patient’s refractive status, corneal condition, dry eye and other eye findings.

Spectacles and Multifocal Contact Lenses

Spectacles and multifocal contact lenses were presented as two options for managing presbyopia.

The presentation then focused mainly on prescription eye drops, monovision, laser refractive surgery, phakic IOLs and the IOL options available when cataract surgery is required.

Prescription Eye Drops for Presbyopia

Prescription eye drops were one of the options discussed.

The presentation identified patients with no cataracts, including those with no refractive error or low hyperopia, as possible candidates for presbyopia eye drops.

Dr Rosman also highlighted possible effects that should be discussed:

• Vision may appear dimmer, particularly at night
• Night-time work and activities should be considered
• Headache or discomfort around the brow may occur

The presence of a cataract affects whether prescription eye drops should be considered.

What Is Monovision?

Monovision corrects the two eyes for different viewing distances.

One eye is corrected for distance vision, while the other is corrected for near vision.

Dr Rosman’s presentation identified monovision as an option that may be considered for people with myopia, particularly those already accustomed to monovision.

Previous experience with monovision may come from:

• Natural monovision
• Monovision contact lenses
• A previous refractive procedure

A contact lens trial was recommended in the presentation before permanent monovision correction.

How Can Monovision Be Created?

Dr Rosman explained that monovision may be created through different approaches:

• Laser refractive surgery
• A phakic intraocular lens
• Cataract surgery

The specific procedure depends on the presence of a cataract, refractive status, corneal condition, dry eye and other considerations.

What Are the Limitations of Monovision?

The presentation identified several possible issues with monovision:

• Reduced depth perception
• Reduced stereoscopic vision
• Eye strain
• A lack of continuous vision across different distances

Dr Rosman also discussed situations in which monovision should be approached carefully or avoided.

These included:

• Patients who require depth perception or stereoscopic vision for their work or activities
• Patients who spend long periods performing near work
• Patients with a pre-existing squint
• Patients with poorer vision in one eye

Patients who are already accustomed to monovision may respond differently from those who have not experienced it before.

Laser Refractive Surgery for Presbyopia

The laser refractive procedures discussed in the presentation were:

• LASIK
• SMILE
• Surface ablation

These procedures may be used to create monovision.

The choice of procedure depends on:

• Whether a cataract is present
• The patient’s refractive status
• Corneal condition
• Dry eye
• Other eye considerations

The presentation also referred to a LASIK approach that introduces spherical aberration in a controlled way.

Phakic IOLs for Monovision

A phakic intraocular lens may also be used to create monovision.

Dr Rosman discussed phakic IOLs for patients whose eyes may not be suitable for laser refractive surgery.

Examples presented included:

• Very high myopia
• A cornea that is not suitable for laser refractive surgery
• Patients who prefer not to undergo a corneal procedure

For an ICL to be considered, the eye requires sufficient anterior chamber depth.

The presentation also discussed an extended depth of focus ICL intended for patients with myopia who do not want monovision. Dr Rosman noted that the available outcome data for this lens was limited.

How the Presence of a Cataract Changes the Options

Dr Rosman stated that once a cataract is present, cataract surgery becomes the surgical option considered.

The lens approaches discussed for cataract surgery included:

• Monovision using monofocal IOLs
• Monovision using monofocal-plus IOLs
• Extended depth of focus IOLs
• Multifocal IOLs

The selected option depends on the patient’s history, refractive status and eye examination.

More information about the procedure is available on the cataract surgery with intraocular lenses page.

Factors Considered When Selecting an IOL

Dr Rosman’s presentation grouped the considerations into several areas.

Patient history

The history includes:

• Occupation
• Daily activities
• Previous eye surgery
• The patient’s objectives

Refractive status

The ophthalmologist considers:

• Whether the patient has myopia or hyperopia
• The patient’s previous refractive status
• Whether the patient is already accustomed to monovision
• Whether the eye is particularly long or short

The presentation noted a higher risk of refractive surprise in very long or very short eyes.

Previous refractive surgery

The ophthalmologist should identify whether the patient has previously undergone laser refractive surgery.

Previous refractive surgery affects the assessment of IOL options and the risk of refractive surprise.

Condition of the eye

The examination considers:

• Dry eye
• An abnormal cornea
• Glaucoma
• The condition of the macula
• Eye anatomy that may affect the position of the IOL
• Other eye conditions

Dr Rosman emphasised the importance of taking a detailed history and conducting a detailed eye examination.

When Monovision May Still Be Considered During Cataract Surgery

Dr Rosman presented monovision as an option for selected cataract patients.

The groups discussed included:

• Patients already accustomed to natural monovision
• Patients who have used monovision contact lenses
• Patients who have previously undergone laser refractive surgery
• Patients with myopia
• Patients concerned about night-vision effects
• Patients with eye conditions that may affect the outcome of an EDOF or multifocal IOL

The limitations of monovision, including reduced depth perception and stereoscopic vision, still need to be considered.

Multifocal Intraocular Lenses

Multifocal IOLs create two or more focal points along the visual axis.

These focal points provide refractive benefit at:

• Distance
• Intermediate distances
• Near

Dr Rosman explained that current multifocal IOL models are generally trifocal lenses.

Trifocal IOLs are intended to provide distance, intermediate and near vision and reduce dependence on spectacles.

Possible Issues With Multifocal IOLs

The presentation identified several possible issues:

• Night-vision symptoms
• Loss of contrast
• Difficulty tolerating multifocal optics
• Insufficient near vision
• Insufficient intermediate vision

Each focal point may produce secondary out-of-focus images. According to the presentation, these images can result in visual disturbances such as glare or halos.

Dr Rosman emphasised patient selection and counselling when a multifocal IOL is considered.

Extended Depth of Focus IOLs

An extended depth of focus, or EDOF, IOL creates a single, continuous and elongated focal point.

The intended purpose is to increase the depth of focus.

Dr Rosman described EDOF IOLs as providing:

• Distance vision
• Intermediate vision
• A continuous range from distance to intermediate

The presentation also noted that near vision may be insufficient with an EDOF IOL.

It described EDOF IOLs as having fewer night-vision symptoms than multifocal IOLs. Dr Rosman also raised the possibility of considering EDOF IOLs in some patients who had previously undergone LASIK, with detailed counselling.

How Occupation and Activities Affect IOL Selection

The presentation discussed how visual requirements differ according to occupation and daily activities.

Multifocal IOLs may be considered for patients whose work requires more near vision.

EDOF IOLs may be considered for patients whose work involves more intermediate vision.

Dr Rosman also noted that multifocal IOLs may not be suitable for certain occupations.

The patient’s daily activities should therefore be discussed before selecting an IOL.

Why Expectations Need to Be Discussed

Dr Rosman highlighted two questions that should be discussed before cataract surgery:

1. Does the patient want to reduce dependence on spectacles, or do they prefer to wear glasses?
2. Which viewing distance is most important: distance, intermediate or near?

The presentation also discussed whether the patient can accept possible visual disturbances.

Patients who expect “perfect vision” or are unable to accept visual disturbances require additional counselling. A monofocal IOL may be considered instead.

Why Previous Laser Refractive Surgery Matters

Many cataract patients may have undergone refractive surgery previously.

Dr Rosman identified corneal topography as part of the assessment for these patients.

His presentation stated that multifocal IOLs are generally not advised after refractive surgery because of:

• A higher risk of night-vision symptoms
• Loss of contrast
• A risk of refractive surprise

EDOF IOLs may produce fewer symptoms, but detailed counselling is required.

Dr Rosman presented monofocal IOLs as the option he would generally advise for these patients.

How Dry Eye Affects IOL Planning

Dry eye can affect biometry measurements and postoperative visual outcomes.

Dr Rosman stated that dry eye should be treated before proceeding with the measurements used for IOL planning.

The condition of the corneal surface is therefore considered before the lens choice is finalised.

Why Corneal Topography Is Performed

Corneal topography assesses the shape of the cornea.

The presentation highlighted several causes of an irregular corneal surface:

• Previous eye surgery
• Corneal scars
• Pterygium
• Corneal dystrophies

An abnormal cornea may affect whether a multifocal or EDOF IOL is considered.

Eye Anatomy and IOL Position

Dr Rosman explained that the anatomy of the eye may affect how well an IOL is centred.

The presentation discussed angle kappa and angle alpha as measurements related to the visual axis, pupil, limbus and optical axis.

If the IOL may not remain in the intended position after surgery, Dr Rosman stated that he would not use a multifocal IOL.

Examples discussed included:

• Subluxated cataracts
• A higher risk of complications during surgery
• Mature cataracts

Multifocal IOLs and Glaucoma

The use of multifocal IOLs in patients with glaucoma was described as controversial.

Dr Rosman stated that he may consider a multifocal IOL when:

• The glaucoma is controlled
• The patient uses few eye drops
• Visual field loss is limited
• Additional counselling is provided

He stated that multifocal IOLs are not advised when the patient uses multiple eye drops or the glaucoma is progressing.

Checking the Macula

The presentation emphasised examining the macula before cataract surgery.

Dr Rosman included a preoperative optical coherence tomography scan of the macula as part of this assessment.

The condition of the macula is one of the factors considered before selecting an IOL.

Dr Rosman’s Approach to IOL Selection

Dr Rosman summarised his approach by placing emphasis on:

• Patient selection
• A detailed history
• A detailed eye examination
• Setting expectations
• Discussing possible side effects
• Selecting a monofocal IOL when eye findings make a multifocal option less appropriate

His presentation concluded that several options are available for managing presbyopia. The selected option depends on the patient’s visual requirements and examination findings.

More information is available on the presbyopia treatment options page.

Frequently Asked Questions

What are the main presbyopia treatment options?

The presentation covered spectacles, multifocal contact lenses, prescription eye drops, laser refractive surgery, phakic IOLs and intraocular lenses used during cataract surgery.

What is monovision?

Monovision corrects one eye for distance vision and the other for near vision.

It may be created with contact lenses, laser refractive surgery, a phakic IOL or cataract surgery.

Why is a contact lens trial recommended before monovision surgery?

A contact lens trial allows the patient to experience monovision before a permanent correction is performed.

What are the possible limitations of monovision?

The presentation identified reduced depth perception, reduced stereoscopic vision, eye strain and a lack of continuous vision across different distances.

What is the difference between multifocal and EDOF IOLs?

A multifocal IOL creates two or more focal points for distance, intermediate and near vision.

An EDOF IOL creates a single, elongated focal point intended to provide a continuous range from distance to intermediate vision. Near vision may remain insufficient.

Why does dry eye need to be treated before IOL planning?

Dry eye can affect biometry measurements and postoperative visual outcomes.

Dr Rosman stated that it should be treated before the measurements used for IOL planning are completed.

Can a multifocal IOL be used after LASIK?

Dr Rosman’s presentation stated that multifocal IOLs are generally not advised after refractive surgery because of the risk of night-vision symptoms, loss of contrast and refractive surprise.

EDOF or monofocal IOLs may be discussed, with the choice depending on the examination and counselling.

Can a multifocal IOL be used in a patient with glaucoma?

Dr Rosman described this as controversial.

He may consider it when glaucoma is controlled, the patient uses few eye drops and visual field loss is limited. He stated that it is not advised when the patient uses multiple eye drops or the glaucoma is progressing.

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This article summarises information presented by Dr Mohamad Rosman during an educational session for eye doctors in Jakarta. It provides general information and does not replace an eye examination or individual medical advice from an ophthalmologist.

Disclosure

In the Jakarta presentation, Dr Rosman disclosed consultancy, lecture and research relationships with several ophthalmic companies.

This article does not include Dr Rosman’s personal cataract surgery results, brand-by-brand comparisons, patient images or product-specific outcome data from the professional presentation.

Source

Dr Mohamad Rosman. Current Management of Presbyopia: Patient Selection. Presented during Beyond 20/20: Mastering Presbyopia Management in Cataract Surgery, Jakarta, 16 August 2026.