For high degrees of hyperopia in presbyopic patients, the best surgical solution is refractive lens exchange. For a younger patient, it is usually preferred to retain the crystalline lens since it provides a range of accommodation and for these people I would recommend wearing contact lenses. Once presbyopia hits in the late 40s, my recommendation shifts to performing a refractive lens exchange. These cases are more challenging because the lens capsule is elastic, the nucleus is soft, the anterior chamber is shallow, and the entire anterior segment is small. In the case shown here, we elected for a toric monofocal IOL and a target of plano instead of using a trifocal IOL. This is because this patient has naturally small pupils both in mesoptic and scotopic environments. With a trifocal IOL the benefit of the diffractive rings would not be achieved. Also remember that smaller pupils give a naturally wider depth of field and this patient does not mind wearing reading glasses for near work and smaller print.
