22 EyeWorld Asia-Pacific | June 2025 SURGICAL OUTCOMES ASIA-PACIFIC PERSPECTIVES Patients opting for a presbyopia correcting or Toric IOL are usually aspiring for spectacle independence, and even a small refractive surprise can result in suboptimal vision and a potentially dissatisfied patient due to the low tolerance of advanced technology IOLs for even minor refractive errors. Modern IOL formulas and toric calculators like the Barrett suite and the Hill RBF have allowed close to 90% eyes achieving an outcome within + 0.5 D SE thereby leaving about 10% patients potentially needing enhancement if symptomatic. This enhancement may be achieved via laser vision correction LVC, toric IOL repositioning, or IOL exchange. Some surgeons are uncomfortable accepting and dealing with such a situation and may avoid discussing & offering enhancements to patients for fear of it being perceived as below standard of care which is far from the truth. It is therefore prudent to discuss, preoperatively, the small possibility of a refractive surprise and the potential need for enhancement when counseling premium IOL patients— preempting an awkward situation later. When dealing with a small refractive surprise in our premium IOL practice we don’t hesitate a trial of refraction and prescribing temporary glasses to patients while we decide the future course. If patients are satisfied with the improved vision through correction, they are usually suitable candidates for enhancement. Options For Enhancement Most often refractive surprises are smaller in virgin eyes without history of prior refractive surgery and best managed with laser vision correction. We typically include Gaurav LUTHRA, MD Director, Drishti Eye Institute 16 Subhash Road, Dehradun, India drgl2020@gmail.com the cost for a potential LVC enhancement into the cataract surgery and having an in house laser refractive facility is most useful. Surgeons who do not have access to in-house laser refractive surgery should establish collaborative arrangements with colleagues to avoid patient dissatisfaction when the need arises. IOL exchange may be better for larger myopic and hyperopic surprises especially in prior refractive surgery eyes where Laser enhancement itself may hold challenges. Presbyopia correcting and toric IOLs are best avoided in eyes with a higher risk of refractive surprises, such as those with uncertain IOL power calculations due to a poor ocular surface or prior refractive surgery—unless the patient is highly motivated and understands the associated risks and potential need for secondary intervention. Some patients may choose not to undergo enhancement if they adapt well enough, but the option must be offered in a timely manner to prevent long-term dissatisfaction. The Light Adjustable Lens (LAL) may be a promising solution for eyes at increased risk of surprise, but it is not not yet available to us in India. To conclude, patients opting for an advanced technology IOL should be counseled on the possibility of a refractive surprise and the potential need for enhancement in about one out of every 10 cases— to avoid embarrassment or miscommunication later if such an intervention becomes necessary. Editors’ note: Dr. Gaurav Luthra disclosed no relevant financial interests. About the Physicians John Berdahl, MD | Vance Thompson Vision, Sioux Falls, South Dakota | john.berdahl@vancethompsonvision.com Lance Kugler, MD | Kugler Vision, Omaha, Nebraska | lkugler@kuglervision.com Relevant Disclosures Berdahl: Alcon, Bausch + Lomb, Johnson & Johnson Vision, Zeiss Kugler: Johnson & Johnson Vision, Zeiss Reference 1. Rohlf D, et al. Outcomes of LASIK vs PRK enhancement in eyes with prior cataract surgery. J Cataract Refract Surg. 2023;49:62–68. This article originally appeared in the March 2025 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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