21 EyeWorld Asia-Pacific | June 2025 SURGICAL OUTCOMES surgery is that they have a higher chance of needing an IOL exchange, and if they’re willing to take the risk of a trifocal IOL in exchange for the vision they want for the rest of their lives, I’m willing to take that risk alongside them as long as we both think that it’s not a failure if we need to take that lens out. Similarly, I tell patients that fewer than 1 in 10 patients will need a laser enhancement after surgery. We include that in the price because we know that it’s going to happen to some patients because our predictive capability isn’t perfect.” Enhancement Considerations Dr. Kugler begins to consider an enhancement for the patient when there is treatable refractive error that is decreasing visual quality. “If the patient is happy with their less-than-optimal vision, sometimes they choose to forego the additional step, but we make it very clear that we recommend it in order to maximize vision quality,” Dr. Kugler said. As with any refractive surgery, ocular surface management before and after is critical, Dr. Kugler continued. Addressing the ocular surface may reduce the need for enhancements or alter key measurements. Dr. Berdahl said he knows an enhancement is on the table if there is 1 D of cylinder or 0.5 D or more of a refractive miss postop. Smaller refractive misses are more of a judgment call. In those latter cases, he relies on a few things. “One is the topography, two is epithelial mapping, three is an assessment of dryness, and four is the OCT. The final common pathway is a pair of temporary glasses; if that patient wears a pair of temporary glasses with that prescription and they say, ‘This is how I want to see,’ I know that a laser enhancement is the move,” he said. When it comes to the epithelium, Dr. Berdahl said one needs to make sure that it’s uniform, clear, and not subclinical EBMD. Other pearls for enhancements that Dr. Berdahl offered are to intervene early with a temporary pair of glasses for unhappy patients. “If a patient’s unhappy at 1 week and they have refractive error, I give a temporary pair of glasses very early for two reasons. One is an unhappy patient is often just a scared patient, and if you can show them that they can see well, they’ll go from being scared to understanding that we’ve got a solution for them. Number two, I know that they don’t have PCO yet. So if they develop early PCO, I know that if the glasses fixed their vision, it’s not the PCO that came later and I can YAG them and do their laser enhancement.” When he determines an enhancement is needed, Dr. Berdahl said research has found LASIK to be more predictable than PRK.1 “The most likely reason for this is that irregular epithelium of older patients is common. So when you do a PRK, you wipe off that epithelium and it grows back in a different, smoother configuration, which is nice, however, it results in less predictable refractions, so we usually do LASIK, if we can,” he said. Forward Thinking When offering advanced-technology IOLs, surgeons must have an enhancement strategy, according to Dr. Kugler. This means not only considering broader access to enhancement tools but also each individual patient’s possible future scenarios. “If a future enhancement is not possible due to abnormal corneas or other comorbidity, a multifocal IOL or IOL requiring a high precision outcome should be avoided,” Dr. Kugler said. “The Light Adjustable Lens [LAL, RxSight] is often a good option in these patients. This is especially relevant for post-refractive patients, who are difficult to enhance after IOL procedures.” If surgeons do not have access to LASIK as a postrefractive cataract surgery enhancement tool, Dr. Kugler suggested partnering with a local LASIK surgeon for these cases as a potential strategy. He again mentioned the LAL as a possible strategy instead of LASIK. “Some surgeons use IOL exchange as an enhancement tool, but doing so does not produce the same level of precision in outcomes, particularly for low amounts of astigmatism,” Dr. Kugler added. Overall, Dr. Kugler thinks that enhancements are among the biggest barriers to adoption of advanced-technology IOLs in cataract practices. “Lack of access to enhancements, or lack of planning for enhancements, is one of the biggest if not the biggest factor to the low adoption rate of premium IOLs,” he said.
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