Cataract Surgery Options: Chart comparing all the types of FDA-Approved Intraocular Lenses

Cataract Surgery Options
The new advances in cataract surgery are truly exciting!
For the first time in the history of mankind, patients with cataracts have the potential to see a wide range of distances after cataract surgery.
Complication rates continue to decrease and options for patients continue to increase. It is the best time in history to be diagnosed with cataracts and have cataract surgery!
While this is excellent news for people with cataracts, it can also be overwhelming.
There are so many options now, it can take a lot of time to research and process a great deal of information to understand which choices are best for each person: for you or a loved one with cataracts.
The best choice of all is to go to a moral, competent, experienced eye surgeon: moral being key here, since there many options have a higher financial incentive for surgeons.  While there is the issue of out of pocket expenses for patients now, the technology available for the right patient does give patients new options for happier, better outcomes.


Sandra Lora Cremers, MD, FACS

Monofocal Crystalens Restor MIOL Tecnis MIOL Rezoom MIOL
Distance Vision Good Good Best Good Good
Intermediate Poor good good good Best
Near Poor Not as good worst Best ok
Halos Glare Least Least of Advanced IOLS & MIOL more likely more likely more likely
Pupil Size (in light) Independent Good for large pupils Best for Independent of pupil size must be >3mm to work
Light Level Independent Less of an issue than other MIOL Need more light to read Independent of light level Less of an issue than other MIOL
Loss of Contrast Sensitivity Minimal-none Minimal-none Possible Possible Possible
Results for Reading, Computer distance vision Will need glasses for reading & computer in majority of cases. Some patients tolerate “mini-monovision”: 1 eye for distance, other eye focused for reading. If tolerate this with contact lenses, you are more likely to tolerate it after surgery. Can decrease depth perception in most patients. 80 percent achieved 20/20 or better near vision quality; Trulign Toric lens: corrects Astigmatism also: 1.25 D, 2.00 D and 2.75 D (at the IOL plane), and can correct astigmatism between 0.83 D and 2.50 D Eliminate need for full time glasses use in 97%; Better for Near Vision and Far Vision;
-Function comfortably without glasses (20/40 or better); 99% distance; 90% intermediate; 74% reading (20/25 or better)
Function comfortably without glasses: 96.9 % near, 89.7% intermediate, 95.5% distance; 88% no dependance on glasses at 6mo; 92% of people who received the technology in the ReZoom® Multifocal IOL experienced spectacle independence for intermediate vision
Blue Blocking: Some Yes (ie, Acrysoft Natural),AcrySof SN60WF No No No No
UV Protection: Yes No Yes Yes Yes
Blue blocking IOLs attenuate blue (440–500 nm)
MIOL=multifocal IOL

There is still a controversy over the use of Blue-blocking IOLs (IntraOcular Lenses).
The key issue with all these reports: can we find published articles or statements from MDs that do not have a financial interest in the company they are reporting about.

Below: both key researchers below (Dr. Henderson & Dr. Mainster) are paid by the key lens companies they are defending/supporting, which muddies the waters a bit.

1. From 2014:

 2014 Jan;25(1):35-9. doi: 10.1097/ICU.0000000000000016.

Ultraviolet-blocking intraocular lenses: fact or fiction.



Ultraviolet-blocking intraocular lenses (IOLs) are used routinely in cataract surgery and are widely accepted. Blue-blocking IOLs, however, have been much debated since their inception. In this article, we will review the advantages and disadvantages of blue-blocking IOLs.


In experimental and animal studies, acute blue light exposure induces retinal damage and the use of blue-blocking IOLs lessens this damage. Many large epidemiologic studies have further investigated this relationship between blue light exposure and the development of age-related macular degeneration, and have shown conflicting results. Visual performance and circadian rhythm disturbances have also been explored in patients with blue-blocking IOLs; no significant negative effects have been shown.


The current literature on blue-blocking IOLs is contradictory. Studies have failed to conclusively prove that blue-blocking lenses provide photoprotection against age-related macular degeneration or cause any significant detrimental effects on visual function or circadian rhythms.

2. From 2011:

Clinical Update: Cataract

Back-and-Forth Controversy on Blue-Filtering IOLs
By Lori Baker Schena, PHD, Contributing Writer
Interviewing Deepinder K. Dhaliwal, MD, Bonnie A. Henderson, MD, and Martin A. Mainster, PHD, MD

Academy members: login to read or make comments on this article.
(PDF 312 KB)
For cataract surgeons, it’s a given that presbyopia-correcting intraocular lenses necessitate more chair time with their patients. Yet instilling realistic patient expectations for the immediate future is only part of the story, according to Deepinder K. Dhaliwal, MD, associate professor of ophthalmology, chief of refractive surgery and director of the cornea service at the University of Pittsburgh. Long-term eye health is of equal importance, especially since Americans are living longer, she said. “When I first started regularly implanting the Crystalens accommodating IOL, I was concerned about the fact that the lens offered minimal if any UV protection. To help protect my Crystalens patients from potentially harmful UV rays, I made it a point to recommend that they wear UV-blocking sunglasses when venturing outside.”
But then data from the Beaver Dam and Blue Mountain studies, which implicated blue-light rays as a risk factor for age-related macular degeneration following cataract surgery, caught Dr. Dhaliwal’s attention. “I realized that UV light was not necessarily a threat to the patient’s eye health once the cataract was removed. Instead, blue light appeared to be more of an issue. And with the exception of one yellow-tinted lens on the market, the other lenses did not block the blue light.”
Dr. Dhaliwal added that while blue light has not yet been directly linked to AMD, “it made sense to offer patients retina protection.” For this reason, when counseling her presbyopia-correcting IOL patients, she now recommends amber-tinted sunglasses, which are designed to block blue light, as opposed to gray-tinted sunglasses. “It’s an issue that could easily be overlooked by busy surgeons, but it has become part of the postoperative protocol with my patients,” she said.
Dr. Dhaliwal’s concern about long-term retina health in cataract patients is shared by other ophthalmologists. It also mirrors one side of a larger issue currently being hotly debated in the ophthalmic community: Do the potential benefits of blue-filtering IOLs outweigh potential drawbacks?
The Case Against Blue-Blocking IOLs
Martin A. Mainster, PhD, MD, is a professor of ophthalmology at the University of Kansas in Kansas City, as well as a physicist and author of more than 30 peer-reviewed articles on photoreception and photic retinal hazards. Dr. Mainster actually introduced the concept of the UV-protective IOL in 1978, but now he notes that “IOLs without UV-absorbing chromophores have been used safely and successfully for more than four decades. That’s why colorless UV-transmitting IOLs as well as colorless UV-blocking and yellow-tinted blue-blocking IOLs are used widely today.”
No cause to fear blue. He added that, in fact, “10 of the 12 major epidemiological studies show no link between environmental light exposure and AMD. Most AMD occurs in phakic adults over 60 years of age, despite senescent crystalline lens photoprotection far greater than that of blue-blocking IOLs. If light does play some role in AMD, then pseudophakes should wear sunglasses in very bright midday environments. Pseudophakes have the freedom to remove their sunglasses for optimal photoreception but not the yellow filters in their IOLs. Blue-blocking IOLs force cataract surgeons to choose fear of the unproven, largely failed phototoxicity-AMD hypothesis over light that patients need for their best possible circadian and dim light photoreception. Growing evidence shows that cataract surgery does not cause macular degeneration so blue-blocking IOLs won’t prevent it.”
Some proponents of blue-blocking IOLs point to a study by Nolan and colleagues investigating whether blue-filtering IOLs affect the density of macular pigment.2 (Macular pigment has been proposed as a protectant against AMD because it absorbs blue light at a prereceptoral level.) The study showed that pigment density increased with blue-blocking IOLs but remained stable with colorless IOLs, Dr. Mainster said, adding that this was “an odd result because the patients’ original crystalline lenses absorbed far more short wavelength light than their implanted blue-blocking IOLs. Also, the relationship between macular pigment and AMD is unproven, and any potential protective value of macular pigment probably lies in its biochemical rather than optical properties.”
The benefits of blue light. Dr. Mainster regards blue light as possibly vital to a number of physiologic processes, and interfering with it may have adverse effects. “Blue-blocking IOLs eliminate half of a pseudophake’s violet and blue light. These wavelengths provide 45 percent of scotopic, 83 percent of circadian and 94 percent of S-cone photoreception. It’s no wonder that blue-blocking IOLs have been shown clinically to reduce photopic luminance contrast, photopic S-cone foveal thresholds, mesopic contrast acuity and scotopic short-wavelength sensitivity,” he said.3
Dr. Mainster’s research with colleague Patricia L. Turner, MD, found that environmental illumination plays a key role in human health because blue-light sensitive retinal ganglion photoreceptors send essential information about environmental light to more than a dozen nonvisual brain centers. This information guides critical daily circadian rhythms, including metabolic homeostasis, sleep-wake cycles and the synthesis of hormones and neurotransmitters.
“Bright, properly timed light exposures profoundly influence human health and psychology,” he said. “In the morning, they facilitate transitioning human physiology from sleep to wakeful demands. In the daytime, they improve mood and decrease depression. Natural light increases cognition and work performance. Blue light accelerates learning. Age-related crystalline- lens yellowing reduces retinal violet and blue light illumination essential for circadian photoreception and dim light vision,” he said. “Thus, it’s no surprise that cataract surgery improves health as well as vision. Insomnia and depression, in addition to increased glare, may well prove to be relative indications for cataract surgery.”4
The Case for Blue-Filtering IOLs
Discussions about the potential disadvantages of blue-filtering IOLs do not escape the attention of Bonnie A. Henderson, MD, assistant clinical professor of ophthalmology at Harvard University: The blue-filtering IOL is the primary lens she uses in her cataract practice, and her patients appear extremely satisfied with this choice. “Although I had never come across any clinical problems or complaints about the blue-light filtering IOLs, I had heard the criticisms and wanted to investigate whether there was any validity behind the claims. The last thing I wanted to do was cause harm to my patients so I decided to undertake a comprehensive literature review.”
No harm from blue-blocking. Dr. Henderson and her colleague, Kelly Jun Grimes, MS, reviewed 56 reports published between 1962 and 2009 that have relevance to blocking blue light transmission. The studies covered topics ranging from sleep disturbance, visual outcomes and cataract surgery to lens transmittance, sunlight exposure and macular disease. Their findings, which were published in the Survey of Ophthalmology, found that 91 percent of peer-reviewed reports concluded that there were no significant detrimental effects of blue-light filtering IOLs on different indicators of visual performance, including visual acuity, contrast sensitivity, color perception and photopic, mesopic and scotopic sensitivities.5 “While some researchers have been vocal in pointing out the potential concerns with these lenses, the vast majority of studies found that any potentially harmful effects on vision were not clinically significant,” Dr. Henderson said. “For example, while the literature shows some decreases in scotopic vision, when accounting for the removal of the aging crystalline lens, the overall effect is a large improvement in scotopic vision regardless of the color of the IOL.”
She added that in clinical studies, the blue-light filtering was well-tolerated, and there were no reports of altered night vision or insomnia. “This finding is important given the theoretical detrimental effects of blue-light filtering on night vision, as well on sleep regulation, melatonin and its effect on the circadian cycle.” The finding is particularly relevant, said Dr. Henderson, given the potential benefit of lowering the incidence or progression of AMD with blue-blocking IOLs.
Are blockers useful? Dr. Henderson stressed that her study did not look at whether the blue-light filtering IOLs are actually beneficial. And, in fact, previous to 2009, the studies were inconclusive.
However, a new study by Gray and colleagues, currently in press in Journal of Cataract and Refractive Surgery,found that patients with blue-light filtering IOLs performed significantly better under driving conditions with glare compared with similar patients who had clear IOLs. And Dr. Henderson noted the study by Nolan and colleagues showing that blue-filtering IOLs affected macular pigment density. 2 “This study demonstrated that patients wearing these lenses had an increase in pigment density, which may have a role in the prevention of AMD,” Dr. Henderson said. “While the observed connection between this increase in pigment density and a reduced risk of AMD development or progression should still be further studied, if it turns out there is a beneficial effect from blue-filtering IOLs, I want to give patients that advantage. In the meantime, it is obvious from the published literature that blue-light filtering IOLs are not harmful and may offer real advantages.”
In Summary
Meanwhile, Dr. Mainster and colleagues believe that blue-filtering IOLs have not been shown to prevent AMD but do reduce the light needed for mesopic, scotopic and circadian photoreception. 3,6,7 Dr. Henderson and her colleagues see no harm posed by blue filters, at least in visual parameters, and feel that the possible protection against AMD is worth it. Their research on blue filters did not, however, establish protection against AMD by blue-light blocking, nor address some of Dr. Mainster’s nonvisual brain center concerns, like photoreception-enabled metabolic homeostasis and the synthesis of various hormones and neurotransmitters.
Dr. Mainster added that “Patients should not lose valuable visible light at a time in their life when they need it the most because of age-related pupillary miosis, photoreceptor loss and decreased environmental illumination. Clinical studies show that blue-blocking IOL filters adversely affect mesopic vision.”6 He said that cataract surgery can improve health as well as vision by increasing blue-light dependent circadian and rod photoreception.4 “If blue-blocking IOLs had been the standard of care for the past few decades, then colorless UV-blocking IOLs could be introduced now as the new ‘premium’ IOLs because they provide dim light and circadian photoreception 15 to 20 years more ‘youthful’ than blue-blockers.”1,2
The color of concern: blue or amber? For Dr. Dhaliwal, the growth in popularity of clear lens exchange, combined with the fact that patients are living longer, make it necessary to take the potential risk of AMD seriously. “If blue-blocking decreases the risk of macular degeneration, then we need to counsel our premium-IOL patients correctly,” she said. “For me, that means ensuring that my patients all understand the importance of wearing sunglasses outdoors, particularly amber-tinted lenses. Our responsibility does not end after we implant an IOL.”

1 Mainster, M. A. Br J Ophthalmol 2006;90:784–792.
2 Nolan, J. M. et al. Invest Ophthalmol Vis Sci 2009;50:4777–4785.
3 Mainster, M. A. and P. L. Turner. Surv Ophthalmol 2010;55:272–289.
4 Mainster, M. A. and P. L. Turner. Sleep Med Rev 2010;14:269–280.
5 Henderson, B. A. and K. J. Grimes. Surv Ophthalmol 2010;55:284–289.
6 Wirtitsch M. G. et al. Ophthalmology 2009;116:39–45.
7 Mainster, M. A. and P. L. Turner. Ophthalmology 2011;118:1–2.

Dr. Dhaliwal consults for Alcon. Dr. Henderson consults for Alcon and Ista Pharmaceuticals. Dr. Mainster consults for Abbott Medical Optics.

To Decide, Read First
Dr. Mainster emphasized the importance of peer-reviewed reports, mentioning his editorial with Dr. Turner on this subject in the January 2011 Ophthalmology. He also suggested reading the Centers for Medicare and Medicaid Services’ analyses in the Federal Register, noting their conclusions in 2005 that “the relationship between blue light and AMD is speculative and not proven by available evidence” and in 2010 that blue-blocking IOLs “do not demonstrate substantial clinical benefit in comparison with currently available IOLs.”
Dr. Henderson agreed that ophthalmologists should scrutinize the published literature. “Reports on this topic, especially in support of blue-light filtration, continue to surface in peer-reviewed literature. For example, a recent article by Billy Hammond and colleagues (Hammond, B. R. et al. Clin Ophthalmol2010;4:1465–1473) found that the filtering of blue light has distinct effects on visual performance by significantly lowering glare disability and improving the visibility of a target in the presence of glare.”


Eye (2012) 26, 1397–1399; doi:10.1038/eye.2012.178; published online 7 September 2012

Blue-blocking intraocular implants should be used routinely during phacoemulsification surgery – Yes

R J Symes1 and F M Cuthbertson2
  1. 1Department of Ophthalmology, Sussex Eye Hospital, Brighton, UK
  2. 2Royal United Hospital Bath NHS Trust, Bath, UK
Correspondence: RJ Symes, Department of Ophthalmology, Sussex Eye Hospital, Eastern Road, Brighton BN2 5BF, UK Tel:+44 (0) 1273 606126; Fax:+44 (0) 1273 553038. E-mail:
Cataract surgery removes a dysfunctional natural lens from the eye, replacing it with an artificial substitute. This substitute must mimic the role of a healthy lens in both focusing light onto the retina and protecting it from damage from electromagnetic radiation. The earliest intraocular lenses (IOLs) fulfilled only part of this requirement, being unable to block out harmful ultra-violet (UV) light. Contemporary clear IOLs do block UV light, but not short-wavelength visible light (blue light: 400–500nm).1 In the phakic patient, the crystalline lens blocks out a proportion of blue light naturally with an increasing amount of blue light blocked with age. Replacing the crystalline lens with a UV-blocking IOL increases blue light transmission, and cataract surgeons are familiar with patients commenting that everything looks ‘bluer’ after surgery (cyanopsia). Blue-blocking IOLs more closely mimic the young crystalline lens, limiting that additional increase in blue-light transmission postoperatively.
In considering which IOL type to use, there are two important questions. Is additional retinal blue-light exposure harmful? Are there any advantages to allowing more blue light into a pseudophakic eye than would be possible even in a young, phakic eye?
That light exposure can cause retinal damage has been recognised for decades, with a number of different mechanisms identified.23 Both experimental and clinical evidence support that damage is caused to retinal and RPE cells by short, high-intensity light exposure, but the risk of long-term exposure to light of ambient levels remains under discussion. RPE cells in the ageing eye accumulate lipofuscin. This contains a fluorophore (A2E), which mediates RPE cell damage following short-wavelength light exposure in animal models and cell culture.4This damage is reduced in the presence of a blue-light filter.1 What is less clear is how this theory translates into clinical practice. Epidemiological studies have been inconsistent, with support for a role for light exposure in the development or progression of age-related macular degeneration (AMD) being seen in some but not all.1 A recent study linked light exposure to AMD development in a subgroup of patients with low macular-pigment levels, macular pigment having a putative protective role.5 This reflects the complex pathogenesis of AMD, with light exposure being just one of many possible contributing factors. There are significant logistical difficulties with such studies, which rely on a retrospective estimate of cumulative light exposure. AMD is a condition with multiple known and emerging risk factors, both genetic and environmental, and for any epidemiological study to be accurate, it must account for all. Because of the complexity of the condition, there is unlikely to be robust clinical or epidemiological evidence to support (or otherwise) the cell culture and animal model data soon; but in the meantime, the theoretical arguments for blue-light exposure causing retinal damage are strong.6
Use of a UV-blocking IOL increases blue-light transmission compared with both a young crystalline lens and a blue-blocking IOL. Is there any advantage to this? It has been argued that improved scotopic vision may be achieved in elderly patients. Rod function declines with age,7 and the rod sensitivity peak is approximately 500nm. Increasing the light input into these cells by removing a blue-light filter may improve vision. Although some theoretical studies have suggested improved scotopic sensitivity in eyes implanted with a clear, UV-blocking IOL compared with a blue-blocking IOL,89 two clinical studies failed to support this.1011 In the industrialised world with its ambient lighting, true scotopic light levels are not often encountered, with street lighting and activities such as night driving falling into the low mesopic range. As such, even if there really was a small difference in performance under true scotopic conditions, it would be unlikely to cause significant difficulty to most people.
Blue light also has an important role in the circadian system, affecting the sleep–wake cycle, mood and cognition.1213 This effect is mediated primarily by photoreceptive retinal ganglion cells (pRGCs) that contain the non-visual photopigment melanopsin and provide input to the hypothalamus.14 Melanopsin has a peak absorption wavelength of 480nm, at the blue end of the spectrum. The most important signal for circadian control is the changing quality of light at the extremes of the day, and in particular, exposure to morning daylight. Theoretical studies have suggested that a reduction in blue light transmission following implantation of a blue-blocking IOL could affect sleep.15 Clinical studies showed no difference between the two IOL types for sleep and quality of life, although numbers were small.1617 To determine whether reduced blue transmission would affect sleep, it is important to consider absolute light levels and requirements. pRGCs act as integrators, meaning that duration of light exposure as well as intensity is important. A healthy, young adult requires 12h of exposure to light of at least 200lux (equivalent to average indoor lighting) to maintain circadian entrainment.18 Daylight is 2–3 log units brighter than this, so even with a blue-blocking IOL, a short exposure to morning daylight should easily suffice for most individuals. Care should be taken, however, for those who do not have natural daylight exposure, such as those who are housebound or in nursing homes.
Blue-blocking IOLs aim to provide patients with a more physiological visual experience by blocking a proportion of blue light in the visible spectrum, equivalent to that which occurs naturally in a young, phakic adult. Although clinical evidence is still lacking, there is convincing theoretical and experimental evidence, suggesting that blue light may have the potential to damage the retina and possibly have a role in the pathogenesis of AMD. Suggested advantages of UV-blocking IOLs remain unproven. We believe that blue-blocking IOLs can be used safely in the majority of patients, and see no reason why they should not be used routinely. Every rule has an exception, however, and we would advocate caution in those with pre-existing sleep problems or who have poor daytime exposure to natural light.


Conflict of interest

RS declares no conflict of interest. FC has received funding to attend conferences from Allergan and Novartis.


  1. Cuthbertson FM, Peirson SN, Wulff K, Foster RG, Downes SM. Blue light-filtering intraocular lenses: review of potential benefits and side effects. J Cataract Refract Surg 2009; 35: 1281–1297. | Article | PubMed |
  2. Youssef PN, Sheibani N, Albert DM. Retinal light toxicity. Eye 2011; 25: 1–14. | Article | PubMed |
  3. Van Norren D, Gorgels T. The action spectrum of photochemical damage to the retina: a review of monochromatic threshold data. Photochem Photobiol2011; 87: 747–753. | Article | PubMed |
  4. Hunter JJ, Morgan JIW, Merigan WH, Sliney DH, Sparrow JR, Williams DR. The susceptibility of the retina to photochemical damage from visible light.Prog Retin Eye Res 2012; 31: 28–42. | Article | PubMed |
  5. Fletcher AE, Bentham GC, Agnew M, Young IS, Augood C, Chakravarthy Uet al. Sunlight exposure, antioxidants, and age-related macular degeneration. Arch Ophthalmol 2008; 126: 1396–1403. | Article | PubMed |
  6. Jackson GRC, Owsley MGJ. Aging and dark adaptation. Vision Res 1999;39: 3975–3982. | Article | PubMed | ISI | CAS |
  7. Margrain TH, Boulton M, Marshall J, Sliney DH. Do blue light filters confer protection against age-related macular degeneration? Prog Retin Eye Res2004; 23: 523–531. | Article | PubMed | CAS |
  8. Pons A, Delgado D, Campos J. Determination of the action spectrum of the blue-light hazard for different intraocular lenses. J Opt Soc Am A Opt Image Sci Vis 2007; 24: 1545–1550. | Article | PubMed |
  9. Mainster MA, Sparrow JR. How much blue light should an IOL transmit? Br J Ophthalmol 2003; 87: 1523–1529. | Article | PubMed |
  10. Greenstein VC, Chiosi F, Baker P, Seiple W, Holopigian K, Braunstein RE et al. Scotopic sensitivity and color vision with a blue light-absorbing intraocular lens. J Cataract Refract Surg 2007; 33: 284–289. | Article |
  11. Muftuoglu O, Karel F, Duman R. Effect of a yellow intraocular lens on scotopic vision, glare disability and blue color perception. J Cataract Refract Surg 2007; 33: 658–666. | Article | PubMed |
  12. Turner PL, Mainster MA. Circadian photoreception: ageing and the eye’s important role in systemic health. Br J Ophthalmol 2008; 92: 1439–1444. | Article | PubMed |
  13. Mainster MA, Turner PL. Blue-blocking IOLs decrease photoreception without providing significant photoprotection. Surv Ophthalmol 2010; 55: 272–283. | Article | PubMed |
  14. Hankins MW, Peirson SN, Foster RG. Melanopsin: an exciting new photopigment. Trends Neurosci 2008; 31: 27–36. | Article | PubMed | ISI | CAS |
  15. Mainster MA. Violet and blue light blocking intraocular lenses: Photoprotection versus photoreception. Br J Ophthamol 2006; 90: 784–792. | Article |
  16. Landers JA, Tamblyn D, Perriam D. Effect of a blue-light-blocking intraocular lens on the quality of sleep. J Cataract Refract Surg 2009; 35: 83–88. | Article | PubMed |
  17. Espindle D, Crawford B, Maxwell A, Rajagopalan K, Barnes R, Harris B et al. Quality-of-life improvements in cataract patients with bilateral blue light-filtering intraocular lenses: clinical trial. J Cataract Refract Surg 2005;31: 1952–1959. | Article | PubMed |
  18. Middleton B, Stone BM, Arendt J. Human circadian phase in 12:12h, 200: <8 lux and 1000: <8 lux light-dark cycles, without scheduled sleep or activity. Neurosci Lett 2002; 329: 41–44. | Article | PubMed |

 2010 May-Jun;55(3):284-9.

Blue-blocking IOLs: a complete review of the literature.


Intraocular lenses (IOLs) that block both ultraviolet and blue wavelength light (<500 nm)were introduced in the 1990s. Since then, the potential benefits and harm from blocking blue light has been debated. We report the results of a complete review of all peer-reviewed published studies regarding the impact of blocking the transmission of blue light. Fifty-six published reports on subjects related to blue-blocking lenses including sleep disturbance, visual outcomes, cataract surgery, lens transmittance, sunlight exposure, and macular disease were found in peer reviewed journals from 1962 to 2009. Eleven reports specifically compared visual outcomes between blue-blocking IOLs and nonblue-locking IOLs. Of these, 10 independent studies (10/11, 91%) concluded that there are no significant effects of blue-blocking IOLs on various meters of visual performance including visual acuity, contrast sensitivity, color perception, and photopic, mesopic, and scotopic sensitivities. Only one group of authors reported that the use of blue-blocking IOLs may have detrimental effects on scotopic vision and circadian rhythms. However, the actual clinical significance of these potential negative effects on scotopic vision and on sleep patterns is uncertain. The benefits of blocking the transmission of blue light to the macula and the relationship between progression of age-related macular degeneration remain unclear. However, the published studies clearly state that the use of blue-blocking IOLs is not detrimental in visual acuity, color perception, and contrast sensitivity. The reported potential negative effects on scotopic vision and sleep disturbance appear to be minimal and may not be clinically relevant. (Surv Ophthalmol 55:284–289, 2010. 2010 Elsevier Inc. All rights reserved.)

6. Specific to Crystalens:




[PubMed – indexed for MEDLINE]

Blue-Violet Subjective Color Changes After Crystalens Implantation

Counseling patients prior to implantation is crucial.

Why does tree bark have a purple tinge? Why do my black socks look deep navy blue? If you listen carefully to patients who have had the Crystalens accommodating lens (Bausch + LombRochester, New York) implanted, you will likely find a small percentage of patients who ask these types of questions. Fortunately, most patients who experience this phenomenon after surgery are accepting of the subjective change in color perception, particularly if they have been counseled about the possible risk as part of the preoperative informed consent process. Unfortunately, there will be an occasional patient who cannot cope with this change in color perception, and these patients can be difficult to manage.
The most important thing a surgeon can do is to let patients know before surgery that change in color perception is a possible reaction and to be particularly cautious implanting these lenses in patients who are color sensitive, such as artists, interior designers, and people who identify themselves as color sensitive.


Color discrimination is a subjective phenomenon. Many patients experience a change in color awareness following cataract surgery with any IOL; however, some Crystalens patients demonstrate a consistent symptom that appears different in character from the usual color changes after cataract surgery. These patients typically have remarkably similar complaints: black appears deep navy, browns and taupes appear purple, and deep reds appear magenta. It is possible that the increased spectrum of light introduced to the retina after Crystalens implantation—due to the lens’ absorption spectrum—may contribute to these symptoms in certain patients. If symptoms are severe, some patients may elect IOL exchange or secondary piggyback implantation of a blue-blocking IOL.
A few case examples may be illustrative of ways to manage this complaint.
Case No. 1. The first patient I saw with this condition identified herself as color sensitive. Prior to surgery, we had many lengthy discussions about implant lens choices and their optical side effects, with specific discussions about color perception issues from different IOL materials that she had researched. She elected a Crystalens AT 50SE, which was implanted in her left eye. The patient’s vision was good immediately after surgery, but later that day she called complaining that there was a purple cast to all colors, especially black. Options were discussed at length, including IOL removal and exchange and possible piggyback IOL placement, but the patient elected to have no further surgery on that eye.
This patient continued to lose visual function from the cataract in her second eye. After she did extensive research regarding different IOL spectral blocking, she asked me to implant a Tecnis 1-Piece IOL (Abbott Medical Optics Inc., Santa Ana, California) in her right eye. Although her vision was 20/20 uncorrected after this surgery, she felt that the color problem was now also present in the second eye, with objects appearing purple in both eyes. She continues to have these symptoms but does not want additional surgery.
FM-100 color testing showed total error scores of 20 for the right eye and 32 for the left. According to the norms described by Verriest et al,1 these scores are, respectively, 4.4 and 3.8 standard deviations better than mean normal for this age group.
Case No. 2. The second patient in my practice to experience this phenomenon had uncomplicated cataract surgery and received a Crystalens HD 520. At the day 1 postoperative evaluation, she achieved 20/20 distance UCVA and J5 and J3 intermediate and near vision, respectively. She was happy with her vision when she left our office but called the next day with two complaints: (1) she had difficulty differentiating black from blue and (2) browns appeared purple. She also wrote a letter explaining her symptoms: “The color distortions that I experienced with the Crystalens became immediately apparent in daylight, especially under morning or afternoon light, and to a lesser extent, under fluorescent light. Blacks registered as navy, taupes became purple, and deep reds were magenta. Moreover, grasses, trees and shrubs were washed out.”
One week after surgery, this patient was happy with her vision, but the color perception symptoms were unchanged. I offered her the options of undergoing a lens exchange or piggyback lens implantation or proceeding with the other eye as scheduled and hoping that the symptom would resolve. After extensive discussion, she elected Crystalens implantation in the second eye. Color perception had not improved 1 week after surgery in the second eye. One of the options I suggested was IOL exchange in either or both eyes, and she elected replacing the Crystalens in the left eye with a blue-blocking acrylic IOL.The color symptoms were immediately and completely resolved in the left eye.
The patient continued to struggle with color perception in the right eye and elected to try piggyback implantation with a blue-blocking IOL. A three-piece blue-blocking IOL with plano power was placed in the sulcus of the right eye. On the first postoperative day, the patient noted complete resolution of the color symptoms and 20/20 distance UCVA but experienced an immediate compromise in her near (J8 vs J3) and intermediate (J8 vs J5) vision.
Case No. 3. The next patient was a 74-year-old male who worked as a professional color matcher. Cataract surgery was performed in his left eye, and a Crystalens AT- 50SE was implanted. The patient was initially happy, but at 6 weeks he returned with symptoms of difficulty discriminating black from blue and brown objects appearing purple. This patient also wrote a letter describing his symptoms and complaints: “I also noticed from the first day after the eye patch removal, colors are very difficult to distinguish. Need wife to advise me on getting dressed.”
The patient elected a blue-blocking IOL for the second eye. Color discrimination improved binocularly, as he had no color distortion with the second eye. He still notices color distortion with right eye when the left eye is closed; however, he has elected to have no further procedures at this time and is happy with his binocular visual function. Case No. 4. After these three patients with notable changes in color perception, I began counseling patients about the possibility of this condition. In this case, after counseling, the patient elected Crystalens AO implants. At 1 week, she complained that colors had a purple cast and plants and trees looked washed out. She also had trouble distinguishing black from blue. She elected to receive a blue-blocking IOL in her second eye and noticed that color looked normal with this implant. However, she decided that the color problem in her first eye was a trade-off for the excellent range of vision with the Crystalens AO. She asked me to exchange the IOL in her left eye for a Crystalens. This patient now has bilateral Crystalens implants with excellent vision. She continues to be bothered by colors not appearing true but feels that the color problem is not very significant.
Case No. 5. A 63-year-old female interior designer was specifically counseled about the possibility of color discrimination problems. She still elected the Crystalens HD. After implantation, she complained of a light purple iridescent haze to all colors but felt that the overall visual quality was good enough that she wanted to go ahead and have the same lens put in the second eye. She continues to report color differences, with more lavender and purple in colors, but has learned to live with it. During a postoperative exam, she said, “I would rather not still have it if I had a choice.”
FM-100 color testing in this patient showed total error scores of 76 for the right eye and 92 for the left. These scores are 0.85 and 0.52 standard deviations better than mean normal for this age group for the right and left eyes, respectively.


I continue to counsel patients about the risk of changes in color perception with this lens, and I continue to have patients who report these symptoms. Within the past month, an artist who received a Crystalens AO noted that a cotton weave red sweater that had previously matched a pair of red wool pants appeared more pink/violet than preoperatively; another patient stated that a previously color-matched black cotton-weave jacket and black polished cotton pants no longer appeared to match, with the pants appearing deep navy and the jacket black. My experience has been that 3% of patients implanted with any generation of the Crystalens IOL experience this subjectively abnormal color perception. I was unable to identify other similar characteristics among these patients, although there was a tendency for them to be more discriminating about color in their day-to-day lives. Two patients showed better-than-average color discrimination with FM-100 testing.
All implant lenses have some degree of ultraviolet (UV) block, and the Crystalens has less than most (to about 355 nm). My initial theory that the level of UV block was the cause of the symptoms led me to offer a lens exchange or a piggyback option to resolve the symptoms. A blueblocking IOL relieved the color symptoms in all patients in whom this option was elected. Unfortunately, a piggyback also apparently decreased the accommodative benefit of the Crystalens in one patient; I cannot explain this phenomenon. The only piggyback IOL with a blue-blocker that I know of is the MN60MA (Alcon Laboratories, Inc., Fort Worth, Texas), which is a three-piece lens that is not designed as a sulcus lens. Thus, this approach should only be used if there is no other option.


Color distortion from implantation of the Crystalens, although apparently uncommon, has been a major problem for some patients. If a patient develops changes in color perception that are intolerable, a different lens can be placed in the second eye with some binocular adaptive success. Alternatively, the lenses can be exchanged for a blue-blocking IOL, or a blue-blocking piggyback IOL can be placed; however, there was some loss of accommodation in the one patient who had a piggyback IOL placed.
I recommend that surgeons implanting these lenses inform their patients about the possibility of subjective color discrimination symptoms, especially if the patient has specific color vision needs or color sensitivity. Patients who have been advised about the possibility of having these symptoms before surgery seem better able to cope with the symptoms after surgery or might elect a different implant option.
Peter J. Cornell, MD, is an Associate Clinical Professor, UCLA Department of Ophthalmology, Beverly Hills, California. Dr. Cornell states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +1 310 274 9205; fax: +1 310 274 7229; e-mail:
  1. Verriest G,Van Laethem J,Uvijls A.A new assessment of the normal ranges of the Farnsworth-Munsell 100-hue test scores.Am J Ophthalmol.1982;93(5):635-642.
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