Refractive
Fall 2025

by Karolinne Rocha, MD, PhD
Refractive Editor

Even with the wealth of new technologies available to help patients reach their optimal visual outcomes, refractive surprises, longer and shorter eyes, and unique medical histories persist. During these times we are called to flex our expertise and go beyond the routine to meet the needs of these patients.

One example is a 71-year-old male with high residual refractive error and contact lens intolerance as well as a history of multiple anterior segment surgeries, including bilateral radial keratotomy (RK), toric IOL implantation, and bilateral penetrating keratoplasties to address high irregular astigmatism and corneal ectasia following RK.¹ In this patient’s case, a piggyback with the implantation of the toric ICL was the best option given the state of the patient’s eye health, medical history, technologies available, and desired visual outcomes.

Nicole Fram, MD, mentions post-RK patients like this one specifically in her list of populations for which she considers piggyback surgery for postoperative refractive surprises as an option in “Piggyback IOLs an important tool for postop precision.” She weighs in along with William Trattler, MD, and together the doctors discuss specific anatomical attributes, such as a deep chamber, and IOL options to consider for meeting the visual demands of these patients. I find secondary IOL implantation can be a good solution in cases where laser vision correction is not an option, to manage unexpected visual outcomes, or to manage complex eyes.

But first, Peter Hersh, MD, and Beeran Meghpara, MD, provide their expertise in “When the cornea is not routine: finding the right refraction in patients with keratoconus.” The doctors address why it’s important for physicians to take into account the impact that high irregular astigmatism will have on the optics. These patients often have higher order aberrations and a multifocal cornea that make refraction challenging. In the article you’ll find strategies for how to overcome these challenges. For example, pupil size changes in keratoconus affect subjective manifest refraction due to the multifocal nature of the cornea. As a result, Dr. Hersh offers the tip to perform the refraction in both photopic and mesopic conditions and prescribe with those findings and the patient’s lifestyle in mind to pair the patient with the correct refraction for their visual demands.

As technology and our understanding of the eye continue to advance, I am consistently reminded that successful ophthalmic outcomes are achieved by going back to the basics. A good refraction, one that optimizes for the patient’s lifestyle and activities or one that corrects for a patient’s residual error following refractive surgery, makes all the difference in identifying the best option for our patients.

Article Sidebar

Blake Williamson, MD, EyeWorld Refractive Editorial Board member, shared how he goes “beyond the routine,” noting that he does virtual 1-day postop visits for cataract surgery.

Reference

1. Rocha KM, et al. Toric implantable collamer lens for treating refractive error in post-radial keratotomy, post-penetrating keratoplasty pseudophakic eye. Am J Ophthalmol Case Rep. 2020:20:100882.