20 EyeWorld Asia-Pacific | June 2025 SURGICAL OUTCOMES Patients who opt to have an advanced-technology IOL (whether it be toric or presbyopia correcting) tend to have higher expectations for their postop vision, and as such, most surgeons proficient with these lenses are prepared to provide enhancements via laser vision correction, IOL rotation, or IOL exchange when necessary. So while some level of enhancements are expected with refractive cataract surgery, what is an “acceptable” enhancement rate? Lance Kugler, MD, first pointed out that we have to agree upon what the criteria ought to be for enhancements. “If we can agree that achieving a spherical equivalent within 0.50 D, with 0.50 D or less of cylinder, is the goal for multifocal IOL patients, the data is quite clear,” Dr. Kugler said. “Most studies that have looked at IOL calculation accuracy have determined that modern formulas can deliver around 80% within 0.50 D of the intended target. The best datasets published are between 90–92%. That means that in the best possible scenario, the best we can hope for is an 8–10% enhancement rate. Informal surveys from experienced refractive/IOL surgeons suggest that a 10–12% enhancement rate is typical in practices that track these outcomes closely.” John Berdahl, MD, said the range is from 2.5–12.5%. “Like anything in medicine, there’s judgment on risk versus benefit. But in our practice, we are very willing to take someone from good to great with even a small correction,” he said. Enhancement Stigma? Dr. Kugler added that he doesn’t think it’s possible to have a less than 10% enhancement rate, per published data. “Certainly a surgeon could decide to have a lower enhancement rate by choosing to not offer enhancements, but that simply means that 8–10% of their patients are not seeing as well as they should be and are likely unhappy,” he said. When asked whether there might be a “stigma” around doing enhancements that could have some surgeons avoiding them, Dr. Kugler said yes. “I think surgeons often think that an enhancement means failure. Patients may think that, too, if they are not properly counseled. In our practice, we tell every patient that they should expect to require an enhancement and that it is a normal part of the process. That way, when needed, they do not interpret it as a failure,” he said. “Our job is not to protect our ego; our job is to get the best possible outcome for the patient,” Dr. Berdahl said. He said that enhancement rates vary from surgeon to surgeon based on their personal judgment, technology available to them, experience with refractive surgery, and use of modern formulas and cataract surgery techniques. However, predicting the future is easy, but being right is hard, he continued. “There are some patients who don’t fall into the exact parameters for IOL calculations or even aberrometry. And there are some patients who don’t tolerate a new optical system that includes multifocality or extended depth of focus,” Dr. Berdahl said. “Our job is to take the patient where they’re at and get them to the best place possible. “Now, surgeons are humans, too, so oftentimes we think of an IOL exchange or a LASIK enhancement as a failure or that we missed. It only becomes a failure when you quit trying to solve the problem,” he said. “My message to patients if they have an eye that’s not pristine before by Liz Hillman, Editorial Co-Director Enhancement Rates: What’s Acceptable And Expected?
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