[epmaybe]

This gets into the weeds a little but the reason boils down to money and tradition, and “what is needed” is a shifting goalpost for society.

Just thirty years ago you may have never even gotten an IOL due to tradition or cost. After adoption in the developed world there was a huge push to prevent lower income countries from accessing the technology because they “didn’t need” that technology and could benefit from lower cost interventions such as glasses.

So as companies started to innovate and lower cost, single vision non toric IOLs became cheap enough for insurance to cover. Then to make some money on premium lenses companies (and ophthalmologists, sadly) really started to push torics and multifocal lenses.

The fact of the matter is that few patients benefit all that much from toric lenses that fix astigmatism. Most people have less than 1 diopter of astigmatic error, which they don’t even manufacture a toric lens for at any usable tolerance (the FDA allows a +/-0.50D tolerance to all lenses including torics), and surgical modifications can nullify that to some extent. Veterans get it free at most VA hospitals though, so they probably get more implanted than the average population.

In the next fifteen years though I bet Medicare will begin to cover toric lenses, and the rest of the insurance industry will follow. The surgery doesn’t change much between toric and non toric. The Multifocal IOLs will remain “premium” for a while to come I expect.

[olliej]

> The fact of the matter is that few patients benefit all that much from toric lenses that fix astigmatism. Most people have less than 1 diopter of astigmatic error, which they don’t even manufacture a toric lens for at any usable tolerance (the FDA allows a +/-0.50D tolerance to all lenses including torics), and surgical modifications can nullify that to some extent.

I do think the cheapness of astigmatism correction in lenses for glasses means that more people get full correction than in the past, but if you're like me and apparently descended from mole people then correcting distance vision alone does squat. My distance vision is far from the worst at 7-8 diopters, so can be mostly corrected with normal lenses, but my astigmatism is bad enough that I wouldn't be able to legally drive without correction. Despite that, instead of getting insurance covered IOLs, I'm paying 3k each for the IOL for each eye.

Only real problem with the one I have so far is that the existing "accommodating" IOLs simply aren't particularly good, and the varying types of multi-focal IOL do cause halos, so if you're like me and already get halos they're off the table. So on the one hand my right eye now has 20/20 vision, on the other: instant presbyopia.

[epmaybe]

My unpopular opinion is that Multifocal and extended depth of field IOLs are all attempting to cheat physics unsuccessfully and are a cash grab by ophthalmologists and manufacturers.

The other option you have is some form of refractive surgery. Also the wholesale cost of a toric IOL is somewhere around $700 so unless the surgeon fee is thru the roof it shouldn’t be costing you $3k each eye.

[olliej]

multifocal ones work for some people, but also fairly often creates halos etc because as you say they're trying to cheat physics and rely on the brain learning what to filter out.

I cannot find any place that is offering $300 toric IOLs, patient cost of tonic IOLs is generally 1100-1500 (with insurance covering the remainder, however it does make me realize that I should get the receipt so I can submit that particular bit to my insurance company directly which I realize they may not have done)

[someweirdperson]

> [...] they don’t even manufacture a toric lens for at any usable tolerance (the FDA allows a +/-0.50D tolerance to all lenses including torics)

I tried a quick google search but couldn't immediately verify. That seems horrible. Really production/specification tolerance, or just eye-correction tolerance to determine the need for a change?

I feel tempted to replace the lenses when eyes have changed by 0.25 (though delaying until 0.5 off). I have returned glasses which were mis-manufactured with the cylindrical axis for one eye off by 10 degrees.