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Editorial Spotlight | October 2019

Managing Unsatisfied Premium IOL Patients

Premium lenses demand a great level of precision in order to deliver the visual function that patients expect.

Enhancements are required of any surgeon who implants premium IOLs because of the level of precision these lenses demand to deliver the visual function that patients expect. Residual spherical error must not exceed ±0.50 D, residual refractive cylinder should be 0.50 D or less, and the postoperative spherical equivalent should be no more than ±0.50 D from plano. If these parameters are not met, almost all patients will be unhappy with their results. When these suboptimal results are not dealt with surgically, patients often obtain contact lenses or glasses from their surgeon or another provider, and they generally will not be singing the praises of the surgeon or the procedure.

So, what are the best strategies for dealing with patients who are unhappy with their outcomes after cataract surgery and premium IOL implantation? The three approaches I use are IOL exchange, piggyback IOL implantation, and laser enhancement in the forms of LASIK or SMILE. For all practical purposes, SMILE should be used only to address low spherical errors because, in the United States, the lowest amount of cylinder that can be treated with this procedure is 0.75 D, and at least -1.00 D of sphere has to be treated with each -0.75 D of cylinder. These amounts are usually larger than the treatment needed after premium IOL surgery, so I usually perform LASIK rather than SMILE to correct residual refractive error.

If a patient has residual hyperopia, then an IOL exchange or a piggyback IOL implantation is a better option. For residual refractive error after implantation of a toric IOL, rotation or exchange of the IOL may be necessary.

It is worth noting that a way to avoid refractive errors after cataract surgery is to implant a Light Adjustable Lens (RxLAL, RxSight). The refractive predictability of the RxLAL matches that of corneal laser vision correction.1 Additionally, patients can help fine-tune the refractive target postoperatively, which is a huge advantage for patients whose cataracts prohibit a preoperative trial. The RxLAL is similary helpful for patients with a history of corneal refractive surgery.

1. Data on File. FDA submission. RxSight.

John F. Doane, MD, FACS
  • Discover Vision Centers, Kansas City, Missouri
  • Clinical Assistant Professor, Department of Ophthalmology, University of Kansas Medical Center, Kansas City, Kansas
  • Editor Emeritus, CRST
  • jdoane@discovervision.com
  • Financial disclosure: Consultant (Carl Zeiss Meditec); Research (Carl Zeiss Meditec, RxSight)
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October 2019