Refractive
Winter 2025

by Karolinne Rocha, MD, PhD
Refractive Editor

With advances in IOL optics and biometry, ophthalmologists are able to meet patients’ visual demands earlier. This has led to a trend as more patients in their 60s are opting to intervene in their aging lenses as a refractive option—about a decade earlier than previously. Many patients who had LASIK about 20 years ago are no longer satisfied with their vision and are looking for a new refractive option to meet their needs.

The precision is so much better today that there’s no need to perform another corneal procedure as we see deterioration in the crystalline lens contrast sensitivity and density, loss of accommodations, and rise of higher order aberrations.

In “Dysfunctional lens syndrome: opening doors to earlier and customized interventions,” Jorge Alió, MD, PhD, Jason Stahl, MD, and George Waring IV, MD, discuss the ways in which the DLS staging system can provide a decision-making algorithm to guide surgical and non-surgical treatments and evaluate corneal versus lens-based surgery options, especially for hyperopic and emmetropic eyes. As Dr. Alió notes in his concern of an increased risk of retinal detachment in moderate and high myopic patients, I agree we need to proceed with caution for lens exchange in this population. However, where his concern is tied to age, mine is tied to ocular health history. Ripandelli et al. found a 1.1% lower risk of retinal detachment in eyes with posterior vitreous detachment compared to eyes without.¹ Dr. Waring also notes how, as a patient education tool, DLS gives ophthalmologists and patients shared access to language to discuss the multiple options available to the patient, including custom lens replacement: “As the terminology became progressively adopted by the medical community, we also saw the adoption start to increase.”

In “Unlocking patient satisfaction after presbyopia-correcting IOLs,” John Berdahl, MD, Eric Donnenfeld, MD, and Vance Thompson, MD, address the most important factors related to patient dissatisfaction, including ocular surface disease issues (dry eye disease and dry eye masqueraders), residual refractive error, posterior capsular opacification, visually significant vitreous floaters, and neuroadaptation. Solutions to treat these issues include dry eye pharmacology, treatment of the eyelid margin disease, refractive enhancement, YAG capsulotomy, or in rare cases, posterior vitrectomy. Alongside setting patient expectations and educating the patient, my colleagues mention it’s often helpful to acknowledge the frustration and fear that patients can feel at this stage. 

Meeting patient expectations for the uniquely visually challenged can take some out-of-the-box thinking. Specifically, for pseudophakic patients who are not candidates for corneal-based procedures, the EVO ICL/EVO toric (STAAR Surgical) may be a safe and effective off-label option to correct high residual refractive errors and enhance satisfaction. Further discussion of which patients can benefit from this clinical approach can be found in “Using the ICL as a supplementary IOL,” where Drew Dickson, MD, Luke Rebenitsch, MD, and Carlos Rocha-de-Lossada, MD, PhD, FEBO, share their experiences. 

The Refractive section of this issue is full of opportunities to open doors and redefine what’s possible for our patients. Continue reading for more on offering refractive options to meet patients’ visual demands, identifying postop challenges and solutions to patient satisfaction, and employing FDA-approved technology.

Reference

1. Ripandelli G, et al. Posterior vitreous detachment and retinal detachment after cataract surgery. Ophthalmology. 2007;114:692–697.