Consensus Is Not Implementation

A new Delphi study on presbyopia-correcting IOLs gives the industry something it has often lacked: unusually broad agreement on what good patient selection and counselling should include.

Twenty-two experienced cataract surgeons in Japan considered 34 statements over two anonymous rounds. Thirty-three reached the predefined consensus threshold of 80%.

That is a strong result. It also creates an uncomfortable question.

If we agree on almost everything that matters, why does adoption remain modest and inconsistent?

The technology is not waiting for permission

The panel agreed that presbyopia-correcting IOLs can improve patient satisfaction and vision-related quality of life when patients are selected appropriately. It also recognised that trifocal and EDOF lenses answer different visual priorities and involve different trade-offs.

Just as importantly, the experts placed patient education, personal goals, costs and expectation management inside the clinical decision—not somewhere around it as optional marketing support.

The barriers they identified were not simply a lack of optical innovation. They included out-of-pocket cost, limited familiarity with payment models, concerns about side effects and outcomes, and gaps in comparative evidence.

None of this translates into “train surgeons to sell harder.” It points to a decision environment that still makes a complex choice more difficult than it needs to be.

Agreement does not redesign a patient journey

A consensus can describe what should happen. It cannot make that experience appear reliably in a clinic.

The patient does not experience a consensus statement. The patient experiences a sequence: what appears in search, what the clinic promises, what the call centre says, which questions are asked before the consultation, how options are explained, when price enters the discussion, and whether somebody checks what was actually understood.

If those moments contradict one another, excellent technology reaches the patient as fragmented information. The surgeon then has to repair the entire pathway in one conversation—or watch the patient quietly return to the default.

The missing layer is implementation architecture

The study independently supports the problem architecture that PDDA® was designed around. It does not test or prove PDDA®, and it would be wrong to claim that it does. The convergence is more practical: both point to patient selection, understandable value, explicit trade-offs, realistic expectations and team support as parts of one system.

Recommendations become useful only when they are translated into operating choices:

1. Before the visit: make the value visible in patient language and align the digital promise with clinical reality.
2. During the consultation: uncover the patient’s visual priorities, narrow the relevant options and discuss limitations as clearly as benefits.
3. At the decision: connect clinical suitability, personal value and cost without turning the surgeon into a salesperson.
4. Across the clinic: define roles, train the team and measure whether the pathway is being used consistently.

That is the work across Smart Values Framework™, Smart Promise Framework™, Smart Sight Framework™ and Easy Lens Selector™. The named tools came later. The operating problem came first.

One failed consensus statement matters

The only statement that did not reach formal consensus proposed that lengthy consultations, physician workload and limited support staff were among the three most important adoption barriers. It received 77% agreement—close, but below the study threshold.

This is not a reason to ignore workflow. It is a reason not to prescribe the same bottleneck to every clinic.

In one setting, consultation capacity may be the constraint. In another, the problem may begin online, sit inside patient selection, emerge when price is introduced, or come from inconsistent language across the team. Diagnosis must come before redesign.

What clinics and brands should do next

For a clinic, the first useful step is not another brochure. It is to map the current decision journey and observe where understanding, confidence or appropriate premium consideration disappears.

For an IOL brand, the task is larger than creating education assets. The brand has to know whether its clinical value survives translation into patient language, whether clinics can integrate the approach into real workflows, and whether a successful pilot can be transferred without depending on one enthusiastic surgeon.

The study gives the industry a credible list of things that matter. The commercial and clinical opportunity lies in making them happen predictably.

Consensus is a starting point

Premium IOL adoption will not become more consistent because the industry agrees harder. It will improve when value becomes understandable, selection becomes personal, trade-offs become discussable and the whole decision journey becomes repeatable.

Consensus tells us where to look. Implementation is how the result changes.

Source: Oshika T, Sasaki H, Arai H, et al. Consensus-based recommendation for presbyopia-correcting intraocular lens use and patient selection: a Delphi study. Scientific Reports. Published 19 August 2026.

Editorial note: this was a Japan-based expert consensus funded by Alcon Laboratories. It is useful external corroboration, not a controlled causal study, a global guideline or independent proof of PDDA®.