What Is Working Now, and What Comes Next?

Aanchal Gupta, MBBS, MMed, Grad Dip (Refract Surg), FRANZCO, FWCRS

Cataract surgery has increasingly become refractive surgery, such that the evolution of modern IOL power calculation formulas has been the single greatest advance in my practice. Formulas such as Barrett, Kane, Hill-RBF, and PEARL-DGS have transformed IOL calculations by combining theoretical optics with AI to achieve levels of refractive accuracy that would have been difficult to imagine a decade ago.^1-4

In my own practice, the Barrett family of formulas, particularly Barrett True-K TK, remains my preferred choice for patients who have undergone previous corneal refractive surgery, where IOL power calculation has historically been one of cataract surgery's greatest challenges.^5,6

As patient expectations continue to rise - particularly in the era of premium IOLs - accurate IOL power calculation has become one of the most important determinants of successful cataract surgery. Although premium IOLs and advanced diagnostics have transformed what we can offer patients, their full potential can be realized only when the intended refractive outcome is achieved.^1-7

Looking 2 to 3 years ahead, the development I find most exciting is the AIOLsci platform developed by Damien Gatinel, MD, PhD, and Benjamin Stern, MD. If the last decade has been about accurately predicting IOL power, I believe the next decade will be about objectively selecting the optimal IOL design for each individual patient.

Current IOL selection is still based largely on biometric formulas that predict postoperative refraction; however, refractive accuracy alone cannot fully predict the quality of vision an individual patient will ultimately experience, particularly in post-refractive and other optically complex corneas. At the same time, surgeons are faced with an ever-expanding range of premium IOLs, each described using different manufacturer terminology and optical concepts.⁷

Recent work by the ESCRS Functional Vision Working Group has highlighted that traditional classifications such as monofocal, extended depth of focus (EDOF), and multifocal often fail to reflect the functional vision ultimately experienced by patients, reinforcing the need for more objective, evidence-based methods of comparing lens performance.⁸

AIOLsci addresses this challenge by combining AI with a physics-based optical simulation engine that integrates each patient's corneal topography, aberrometry, and measured IOL optics.⁹ Rather than simply predict postoperative refraction, it simulates the expected visual performance of different IOL designs - including distance, intermediate, and near vision, contrast behavior and dysphotopsias - allowing surgeons to compare lenses before surgery in the individual eye.⁹

By integrating objective optical modeling with sound clinical judgment, technologies such as AIOLsci have the potential to support more informed, manufacturer-independent IOL selection and ultimately deliver truly personalized visual outcomes for each patient.

1. Kane JX, Chang DF. Intraocular lens power formulas, biometry, and intraoperative aberrometry: a review. Ophthalmology. 2021;128(11):e94-e114. doi:10.1016/j.ophtha.2020.08.010
2. Melles RB, Holladay JT, Chang WJ. Accuracy of intraocular lens calculation formulas. Ophthalmology. 2018;125(2):169-178. doi:10.1016/j.ophtha.2017.08.027
3. Armia A, Sandali O, Tahiri R, eds. Cataract Surgery: Practice, Technique and Innovation. Springer Nature Switzerland; 2026.
4. Rampat R, Gatinel D. Multifocal and extended depth-of-focus intraocular lenses in 2020. Ophthalmology. 2021;128(11):e164-e185. doi:10.1016/j.ophtha.2020.09.026
5. Lawless M, Jiang JY, Hodge C, Sutton G, Roberts TV, Barrett G. Total keratometry in intraocular lens power calculations in eyes with previous laser refractive surgery. Clin Exp Ophthalmol. 2020;48(6):749-756. doi:10.1111/ceo.13760
6. Wang L, Koch DD. Intraocular lens power calculations in eyes with previous corneal refractive surgery: review and expert opinion. Ophthalmology. 2021;128(11):e121-e131. doi:10.1016/j.ophtha.2020.06.054
7. Grzybowski A, ed. Artificial Intelligence in Ophthalmology. Springer Nature Switzerland; 2021.
8. Ribeiro F, Dick HB, Kohnen T, et al. Evidence-based functional classification of simultaneous vision intraocular lenses: seeking a global consensus by the ESCRS Functional Vision Working Group. J Cataract Refract Surg. 2024;50(8):794-798. doi:10.1097/j.jcrs.0000000000001502
9. Gatinel D. AIOLsci. Accessed August 24, 2026. https://www.aiolsci.com

D. Brian Kim, MD

I have built much of my practice around complex cataract cases - postoperative refractive surprises, bothersome dysphotopsias, uveitis-glaucoma-hyphema syndrome, dead bag syndrome, and dislocated IOLs - which has required me to develop the skills to fixate IOLs in the absence of capsular support. I am grateful for the innovative leaders who pioneered scleral IOL fixation techniques, but these techniques generally involve off-label use of IOLs and carry inherent risks and limitations.

A potential solution I will be watching closely is the LensOne (Long Bridge Medical). This prosthetic capsular bag is made of a flexible silicone elastomer with a central IOL housing, a posterior opening, and an awning that covers the optic-haptic junction of a one-piece acrylic IOL. Three arms positioned 120 degrees apart with footplates are designed to fit between the sclera and Tenon capsule, and the goal of the three-point fixation is to improve alignment and reduce tilt and decentration.

Clinical studies have evaluated the LensOne with monofocal one-piece acrylic IOLs.¹ Insertion is versatile; the IOL may be preloaded inside the prosthetic capsular bag or injected first, with secondary IOL insertion. According to Ayman Naseri, MD, CEO of Long Bridge Medical, although IOL removal from the LensOne was not part of the human trials, removal has been relatively straightforward in bench and laboratory testing.

Historically, IOL surgery has been framed as a "one and done" procedure. The LensOne could herald a paradigm shift, potentially opening new refractive options for patients with safe and, in principle, limitless exchangeability. Time will tell once we surgeons gain more experience with the device.

1. Brodie FL, Naseri A, Ho IV, et al. Clinical Outcomes of a Prosthetic Capsular Bag for Scleral Fixation of an Intraocular Lens in Eyes without Capsular Support. Ophthalmology. 2026;133(8):965-970. doi:10.1016/j.ophtha.2026.04.021

Morgan Micheletti, MD

The biggest changes in my practice have come from expanding options. In cataract surgery, a broader range of presbyopia-correcting IOLs has made conversations about spectacle independence more individualized. In glaucoma, a growing evidence base has supported a broader role for intervention, with a toolkit that now spans first-line selective laser trabeculoplasty, sustained-release drug delivery with the travoprost intracameral implant (iDose TR, Glaukos) and bimatoprost intracameral implant (Durysta, AbbVie), and procedures that can be performed either independently or with cataract surgery. Refinements in canaloplasty, including modifications to the Streamline Surgical System (New World Medical) and the green-illuminated iTrack Advance (Nova Eye Medical), have further broadened how and when we surgeons can intervene. Digital planning with the Veracity Surgery Planner (Carl Zeiss Meditec) has improved efficiency and precision by connecting diagnostic data to the surgical plan and reducing manual steps from the clinic to the OR.

In the next 2 to 3 years, I will be watching investigational technologies that could expand that toolkit further, including SpyGlass Pharma's Bimatoprost Drug Pad-IOL System, Glaukos' next-generation iDose TREX platform, ViaLase's femtosecond laser trabeculotomy platform, and Bausch + Lomb's Elios System for excimer laser trabeculostomy. I am also excited about Unity Dx, Alcon and RxSight's adjustable presbyopia-correcting IOL collaboration, more ergonomic microscopes and visualization systems, and practical AI and electronic health record integrations that could reduce repetitive documentation and data entry. The BIM-IOL System, iDose Trex, ViaLase femtosecond laser trabeculotomy platform, Elios System, and adjustable presbyopia-correcting IOL technologies discussed are investigational or under development in the United States and are not currently commercially available in the United States. The most meaningful advances will expand treatment options while making care more connected, efficient, and individualized.

Radhika Rampat, MBBS, BSc(Hons), FRCOphth, FWCRS

If I had to pick one advance that has genuinely changed my practice, it is modern IOL power calculation. During my Paris fellowship 8 years ago, I was fortunate to work with Dr. Gatinel and colleagues on the PEARL-DGS formula¹ and its underlying data, and it transformed outcomes in the cases that used to keep us awake at night - eyes with a history of laser vision correction, unusual axial lengths, and irregular corneas. Those patients now walk in expecting spectacle independence, and more often than not, we can deliver it.

The next layer excites me more: matching the lens to the individual cornea. Platforms such as AIOLsci² are moving us from choosing an IOL off the shelf toward simulating how a specific optic performs in a specific eye by accounting for its corneal aberration profile.^3,4 Cataract surgery becomes truly refractive surgery - personalized at the level of the whole optical system - as it should be because that is exactly what our patients now expect.

In the next few years, I will be watching two things closely. The first is robotics,⁵ which could standardize the most delicate steps of surgery with a consistency the human hand cannot replicate, while leaving the surgeon firmly in control. The second is full workflow integration - patient communication, diagnostics, planning, the OR, and outcomes as one seamless pathway - where every result improves the next patient's plan.

Our job is using these tools together while prioritizing our own judgment and the patient experience. Technology should serve the person in the chair, never the other way around.

1. Debellemaniere G, Dubois M, Gauvin M, et al. The PEARL-DGS formula: the development of an open-source machine learning-based thick IOL calculation formula. Am J Ophthalmol. 2021;232:58-69. doi:10.1016/j.ajo.2021.05.004
2. Stern B. From empiricism to simulation: a new era in cataract surgery planning. The Ophthalmologist. April 14, 2026. Accessed August 24, 2026. https://theophthalmologist.com/issues/2026/articles/april/from-empiricism-to-simulation-a-new-era-in-cataract-surgery-planning
3. Holladay JT, Piers PA, Koranyi G, van der Mooren M, Norrby NES. A new intraocular lens design to reduce spherical aberration of pseudophakic eyes. J Refract Surg. 2002;18(6):683-691. doi:10.3928/1081-597X-20021101-04
4. Kasper T, Buhren J, Kohnen T. Visual performance of aspherical and spherical intraocular lenses: intraindividual comparison of visual acuity, contrast sensitivity, and higher-order aberrations. J Cataract Refract Surg. 2006;32(12):2022-2029. doi:10.1016/j.jcrs.2006.07.029
5. Bourcier T, Chammas J, Becmeur PH, et al. Robot-assisted simulated cataract surgery. J Cataract Refract Surg. 2017;43(4):552-557. doi:10.1016/j.jcrs.2017.02.020

O. Bennett Walton IV, MD, MBA

Patients' desire for the crispest vision, the fullest range of vision, or both has continued to drive growth in the presbyopia-correcting and adjustable-lens spaces. What used to be a binary decision of monofocal or multifocal IOL has become an opportunity to personalize each patient's vision plan. We surgeons can choose from among several presbyopia-correcting lenses. We may maximize their range of vision with a trifocal lens, such as the PanOptix Pro (Alcon) or enVista Envy (Bausch + Lomb), or prioritize a combination of range and easier nighttime vision with a modern EDOF IOL, such as the Clareon Vivity (Alcon) or Tecnis PureSee. Alternatively, we may implant a Light Adjustable Lens (RxSight) so that patients can "test-drive" their vision before the result is locked in.

The next step, as Alcon and RxSight recently announced, may be to combine the accuracy of adjustable lenses with presbyopia-correcting platforms. The holy grail remains a full range of vision in optimal focus without optical side effects. With each product cycle, I expect the optical quality of full-range lenses to improve and the range of the lower-dysphotopsia presbyopia-correcting lenses to expand.

Robert J. Weinstock, MD

No single innovation during the past year stands out in my mind, but the sheer magnitude of IOL designs and choices continues to broaden the optical technology available to our patients. In the past year alone, the US FDA has approved the FineVision HP trifocal IOL (BVI), the Tecnis PureSee EDOF IOL, the RayOne EMV Toric monofocal-plus IOL, and the Clareon TruPlus enhanced monofocal IOL (Alcon).

Understanding how these lenses work and which patients to use them in almost requires a PhD in optics - and another in psychology. Fortunately, a growing number of fellowships in refractive, cataract, and complex anterior segment surgery are giving younger surgeons the experience to know when, why, and how to deploy these technologies successfully. The long-term test of a refractive cataract surgeon is how well they use modern optics to reduce patients' reliance on glasses and how well the surgeon stays out of trouble through disciplined patient selection and execution. I see no end in sight to the refinement of IOL optics.

Blake K. Williamson, MD, MPH

The recent innovation that has had the greatest impact on my practice is the continued evolution of advanced presbyopia-correcting IOLs. The past few years have brought a flurry of platforms I have had great success with, including the Tecnis Odyssey, enVista Envy, RayOne EMV, and Tecnis PureSee. Plus, the FineVision HP and RayOne Galaxy IOLs are now on the horizon. We surgeons have moved beyond simply restoring patients' vision after cataract surgery to delivering refractive outcomes that meaningfully reduce their spectacle dependence while maintaining a high level of satisfaction. Thanks to improvements in lens technology, diagnostics, and patient selection, we can now offer a level of visual performance that was not possible 5 years ago.

I am excited about the recent announcements from Alcon and RxSight on new adjustable lens technologies. Beyond that, I am most excited about the integration of AI throughout the cataract patient's journey. AI could enhance everything from patient education and expectations management to surgical planning, diagnostics, workflow optimization, and postoperative care. I expect AI to augment rather than replace physician judgment, allowing us to spend more time where we add the most value: building relationships, making nuanced clinical decisions, and delivering exceptional surgical care. I believe the practices that combine outstanding clinical expertise with intelligent automation will be best positioned to elevate both the patient experience and practice efficiency.