KOL KNOCKOUT^TM CATARACT EDITION Beyond BCVA: Ensuring Patient Satisfaction in Refractive Outcomes

Today, meeting expectations after cataract and refractive surgery goes well beyond best-corrected visual acuity. In addition to the clinical factors, intraocular lens (IOL) selection is part psychology, requiring you to understand the patient’s personality, lifestyle, occupation, and overall goals.^1-4 Captured from a series of three “knockout rounds,” this supplement summarizes a discussion on how to manage challenging cases. 

— Blake K. Williamson, MD, MPH, MS, Program Chair

ROUND 1 | CASE 1: VETERINARIAN WITH EARLY CATARACT WHO DESIRES SPECTACLE INDEPENDENCE 

Dr. Williamson: This is a 59-year-old female with early cataract. She is a veterinarian and is looking for vision correction with spectacle independence. She has a history of LASIK OU with Raindrop OS in 2016 and Raindrop removal in 2020. Her manifest refraction is +1.00 OD correcting to 20/30-, and +1.25 OS, also correcting to about 20/30-. Before I go any further, let’s look at her anterior segment (Figure 1). Dr. Nasser, what do you observe?  

Taj Nasser, MD: There is obviously some corneal haze. Although we thought the Raindrop and corneal inlays would work well, with time, we noticed that corneal haze developed in these patients.⁵ It’s something we need to keep in mind.

Dr. Williamson: If you look at her topographies (Figure 2) not much stands out. She has a small amount of irregular astigmatism OD and residual cylinder OU. What is your approach to a postoperative corneal inlay patient who now seeks refractive cataract surgery?

Figure 1. Baseline anterior segment imaging. 

Figure 2. Baseline imaging.

Julie Marie Schallhorn, MD: I had similar patient in my practice a couple of months ago. There have been two major types of corneal inlays in the United States: the Raindrop and the Kamra.⁶ I would treat them differently. Patients have had few issues with the Kamra. I’m hesitant to leave in a Raindrop because of the history of fibrosis that’s been reported, the incidence of which increases over time.⁷ I don’t want do perform cataract surgery based on that keratometry and ocular surface profile, only to then have to remove the inlay 2 years later, leaving the patient massively hyperopic. In Raindrop patients, I remove the inlay, let the topography settle, and let the epithelium remodel. After that, I obtain the biometry and perform cataract surgery. 

F. Beau Swann, MD: It’s important to note that the coma on the OPD-Scan III is 0.17, which means her dysphotopsia profile is going to be very low postoperatively. The challenge with managing patients who have an inlay removed is you don’t know what their numbers were before, and that’s important when you select an IOL. The Light Adjustable Lens (LAL) shines in this situation because it’s adjustable. I agree with Dr. Schallhorn’s approach. After you let the eye settle, you obtain the biometry and discuss IOL options. A multifocal will not work well in this situation, but the LAL or LAL+ may achieve that enhanced depth of focus. We can take a mismatch approach with micro-monovision, targeting -0.25 D in the dominant eye and -0.75 D in the nondominant eye. That will achieve the range she’s looking for without the dysphotopsias. 

Dr. Williamson: Dr. Nasser, this patient wants spectacle freedom. What lens would you select? Would you use a femtosecond laser during surgery? What is your target? 

Dr. Nasser: Before I answer those questions, I’d like to comment on wavefront aberrometry. Her higher order aberrations (HOAs) profile is mild, measured at a 6-mm pupil. I don’t see many patients with 6-mm pupils. That’s something to consider in patients with HOAs. Although we could consider a trifocal IOL, I’m concerned about the overall quality of vision this patient will to achieve because of the central haze.

I would select the LAL+ for this patient and give her mild blended vision. For the dominant eye, I would target plano. In the nondominant eye, I would target -0.50 D to -0.75 D for mini-monovision. I’d treat the astigmatism as well. 

Regarding surgical tools, we primarily use the femtosecond laser for all of our patients who select a premium lens. The haze is centrally located. If there was haze peripherally where the capsulotomy would be created, I’d need to be cautious with femto. However, for this case, there’s no issue.

Dr. Schallhorn: One quick point of clarification on the HOAs. I agree that there’s not much HOA showing on the OPD. The OPD is based off of the corneal topography. There’s no wavefront or a ray tracing component, so you’re not picking up any of the scatter from that haze in that OPD scan. The haze is likely not visually significant. If this patient were motivated and accepted the potential dysphotopsia profile, she may be able to use a diffractive multifocal lens.

However, given the fact that she tolerated the Raindrop well, and it was removed for the haze concern and not for a functionality concern, she seems to do well with a monovision approach. I agree with Dr. Nasser that the LAL works beautifully in these postrefractive cases because you can nail that uncorrected distance visual acuity. The greatest predictor of patient satisfaction postoperatively will be their uncorrected distance visual acuity. You can do that with the greatest accuracy with the LAL and the LAL+. 

In terms of target, I usually target both eyes for distance in a patient like this because adjusting myopic is easy with the LAL, and you don’t have to worry about cylinder. That way, the patient can try the blended vision or mini-monovision in the office before you put it into the lens. I would also correct the astigmatism. Regarding the femtosecond laser, I don’t use it anymore because it slowed us down, and there hasn’t been any demonstration in difference of outcomes between manual and femtosecond.⁸

To summarize, I’d select the LAL with manual surgery. I’d put the patient in the driver’s seat, target both eyes for distance initially, and then adjust for mini-monovision.

Dr. Swann: I would not consider a multifocal in this patient because she’s a type A veterinarian. I think the point is very well taken that she is someone who tolerated Raindrop when not many patients did. However, there are several red flags with this case. If I miss the mark by a small amount, how do I proceed? Do I perform PRK on top? Do I perform LASIK? Do I lift the flap? There’s not a lot off wiggle room here.

I love the point of putting the patient in the driver’s seat, but I’d take the opposite approach. I start her with mini-monovision, and then if she doesn’t like it, I start backing her out. It gets her involved. I would also select the LAL+.  

I’m a huge proponent of the femtosecond laser, especially for my toric and LAL patients. We are programming the lens for astigmatism correction, and the laser will draw a perfect circle every time. 

Dr. Williamson: I went with Dr. Schallhorn’s approach. The corneal haze looked a lot worse in the photograph than it did at the slit lamp. The patient, although a veterinarian, is agreeable with a wonderful temperament. She didn’t love her visual experience with the Raindrop, where one eye was different than the other. She did not prefer monovision, and the most important thing to her was high-quality near vision without reading glasses. We tried contact lenses, and she hated it. I decided to touch her up. I did an explant because I didn’t want to perform PRK on top of it. I used the Odyssey OD and the Symfony toric OS. She was plano 20/20 J2 OU on day 4. She’s very pleased. 

ROUND 1 | CASE 3: 40-YEAR-OLD WHO CORRECTS TO 20/20 AND DESIRES A CLEAR LENS EXCHANGE 

Dr. Williamson: Our next case is a 40-year-old male who presents complaining of problems seeing at distance OU. He sees well at distance and near with contact lenses, but he’s seeking a surgical solution to see far and near. He has a friend who had success with a custom lens replacement. The slit lamp exam reveals a normal, clear lens of a 40-year-old healthy eye. The manifest refraction shows -7.50 +2.00 x99 20/20 OD and -6.00 +2.75 x89 20/20 OS. There’s quite a bit of myopia and cylinder with the rule there, but the patient refracts to 20/20.

Figure 3 shows his baseline images. Not much jumps out other than the axial length. We didn’t obtain a good view of the macula, but it appears normal. He has regular astigmatism. The tomography looked good and matched with the topography. Dr. Swann, what is your approach with a high myopic presbyope who wants a clear lens exchange? How do you set expectations? 

Figure 3. Baseline images.

Dr. Swann: This is the gray box in our world. What makes high myopes a little easier to treat is they’ve lived with horrible vision their whole life, so you have some ground to gain. If this was a patient with a low amount of myopia, who’s a presbyope, I would try to talk them out of a clear lens exchange. An implantable contact lens (ICL) is a great option in these cases. I’d first refer this patient to a retinal specialist to ensure his retina won’t detach. As long as all the retina precautions are taken, I think a clear lens exchange is reasonable. He has regular astigmatism and a lot to gain. I think he will be very happy with the results.

You do have to discuss expectations with the patient, telling them it won’t be as smooth of a transition like going from glasses to contacts. There will be specific focal points, and it won’t be perfect.

Dr. Williamson: Dr. Nasser, do you have any hesitations about operating on a patient with 20/20 VA?

Dr. Nasser: That’s a great question. They may be correctable to 20/20, but they still have a quality-of-life issue. If they lose their glasses or contacts, they are functionally blind. I think this is an important point when we think about patients from a refractive mindset. We have to strive to offer patients what will safely reach their goal. The last thing I want them to do is to sleep in contacts and have an infection. Although this patient's VA is correctable to 20/20, I think it’s important to address their refractive error in a safe manner. I agree with Dr. Swann. I would refer him to a retina colleague for a peripheral exam. We must obtain retina clearance first. 

Blended ICLs are a great option. I’d first try a contact lens trial to see if he liked blended vision, and bridge him until it’s time for refractive lens exchange after he’s had a posterior vitreous detachment (PVD).

Dr. Williamson: Dr. Schallhorn, many of our retina colleagues don’t want us offering a refractive lens exchange unless the patient has had a PVD.⁹ What are your thoughts on this? 

Dr. Schallhorn: After you have a PVD, your risk of developing a retinal detachment postoperatively drops down to the lowest risk category. In this patient, a 40-year-old with a 29-mm eye that has not had a PVD, he could have as high as a 1 in 16 risk of a retinal detachment with a clear lens exchange. Even if retina clears him, the patient needs to be aware of that risk.  

I tend to agree with Dr. Nasser about trying out mini-monovision first. He could be out of readers until about age 55, which is excellent. He’ll have a PVD by the time he’s 55 years old, and you could safely do a clear lens exchange at that point. LASIK isn’t out of the question. If he’s not an ICL candidate, or doesn’t want ICLs, LASIK is a reasonable option. 

Dr. Swann: I wouldn’t select LASIK for this patient. Although they have 5 to 10 years left of good accommodation, I don’t want them to take on the LASIK expense if it may only last 5 years. The mini-monovision is a good idea that I had not considered. Our multifocal IOLs are much better than they used to be. I think the patient would be very happy with a custom lens replacement. They’re young and have neuroadaptation. They will get used to the presbyopia. For these reasons, I’d select a bilateral toric, multifocal, clear lens exchange.

Dr. Nasser: I’m comfortable selecting whatever the patient is most motivated about. If they really want a lens replacement, I will discuss their risk of retinal detachment and have a retina specialist clear them. If it were my eye, I would go with toric ICLs, blended. 

Dr. Schallhorn: I like both the LASIK and the toric ICL options. I favor LASIK in this case just because this patient is in exactly the right spot where we have our absolute best LASIK outcomes. LASIK has the highest predictability and the lowest complication rate. I could be persuaded to use a toric ICL. I would not select a custom lens replacement because I do not like the risk category this patient falls into. 

Dr. Williamson: I went with the toric ICL approach. I like that we can avoid a large ablation on a patient who will be presbyopic soon and may want a lens-based approach to treat his presbyopia. I want to avoid multifocality in a young patient who is not currently presbyopic, because it could be a decade or more before the patient needs readers.

ROUND 2 | CASE 1: PATIENT WITH SICKLE CELL ANEMIA AND PRIOR REFRACTIVE SURGERY

Dr. Williamson: This is a 48-year-old male with a history of sickle cell anemia who comes in for vision correction. He had LASIK 20 years ago, but he states it “wore off,” and he’s been wearing contacts for years. He saw a retinal specialist and said he had “something lasered years ago.” His manifest refraction is -3.75 +2.00 x014 20/20 OD and -4.25 +3.00 x175 20/20 OS. He is myopic and has some cylinder but corrects to 20/20. The exam reveals trace nuclear sclerotic cataract. Figure 4 shows his tomography. How would you manage this patient, who has had prior refractive surgery, retina history, some drift, and early cataract? 

Figure 4. Baseline tomography.

Dr. Nasser: This is an interesting case because this is a relatively young patient with an early cataract. I’m concerned from a retina standpoint regarding stability and would want to dig more into the retina history before proceeding with a recommendation. I would counsel this patient heavily. Do I want to perform another corneal refractive surgery on this patient? I’m not keen on lifting old LASIK flaps, especially in this individual. PRK would require multiple discussions with the patient. Sometimes no surgery is the answer for patients who present like this.  

Evan D. Schoenberg, MD: I agree that sometimes the answer is no surgery or no surgery right now. This patient has a lot of astigmatism considering he had LASIK 20 years ago. Sometimes the drift we see is just a spherical drift; they’re becoming more myopic over time. I also noticed on the tomography that the posterior curvature of the cornea shows focal elevation in the inferior periphery. This could be an artifact of a high myopic cornea or suggestive of early, postrefractive surgery ectasia. I would also want to ensure stability before recommending a surgical solution. I’d like to repeat the refraction and tomography in 6 months to see how this is tracking.

Once we have determined they are stable and will be stable long term, I’d lean toward a lenticular procedure for longevity. If they are not stable, I’d consider corneal cross-linking (CXL). If his 20/20 VA is soft with ghosting, which could be suggested by the small amount of radial skew in the topography OD, I’d consider performing topography-guided PRK to tune up the cornea before proceeding with the lenticular approach.

Brett Mueller, MD: I’m also concerned that there’s lingering post-LASIK ectasia considering the astigmatism. I think a multifaceted approach is warranted because they could have progressive ectasia. I’d need to discuss the possibility of CXL before doing anything else. Or, if I perform a lens-based surgery, the patient may need to be closely monitored for progression postoperatively. If they do progress, then they’ll need CXL. This is an interesting case that will require multiple visits and lots of discussions with the patient.

Dr. Williamson: The cornea and refraction were stable and had been for 2 years. At that point, I considered several options. Would PRK be the best solution for his myopia and astigmatism? Is there a way I could use a toric ICL? He has space, but with that spherical covalent, I don’t know if that’s the best option. I considered a lens-based approach. He doesn’t have true cataracts and his VA corrects to 20/20. Do we discuss specialty fit contact lenses? What lens-based approach might you use to achieve spectacle freedom in this patient?

Dr. Mueller: I don’t like performing PRK unless it’s a myopic ablation pattern. I ruled out a PRK when I saw his refraction. A toric ICL isn’t the best option given the nuclear sclerotic changes. For a lens-based solution, I’ve used plenty of diffractive optics and trifocal IOLs in patients with prior refractive surgery. For this particular case, the ablation looks irregular to me, which rules out diffractive optics. I’m leaning toward a Vivity toric lens with a blend, targeting plano in the dominant eye and -0.50 D or -0.75 D in the nondominant eye. He can achieve good spectacle independence with that, but he still may need some reading glasses.

Dr. Schoenberg: I’d also take a close look at these corneas. Although I’ve had success with select eyes using diffractive optics with a previous clean, low myopic, well-centered ablation, I’m not convinced that describes this patient. If they are adamant about total spectacle independence, I’d consider a lens exchange after showing them stimulated views of trifocal optics. My primary recommendation is the LAL with a small blend as our initial target. I’d consider inducing extended depth of focus (EDOF) in the nondominant eye depending on how his optics are before we make that change. 

We can potentially select LAL on EDOF if you target a little bit near. That can be decided after the fact. I would not start with the LAL EDOF because I'm concerned he won’t achieve the precise vision quality he's desires. I like the possibility of leaving the dominant eye with a pristine monofocal optic, but then having flexibility with the LAL adjustments.

Dr. Nasser: Based on the refraction, this patient is a candidate for a toric ICL. They meet the spherical equivalent cutoff in both eyes, but it’s borderline OS. Again, this early nuclear sclerosis steers us away. If the patient had a clear lens, then my top choice would be a toric ICL. However, given that this patient is in the presbyopic range and we are considering a clear lens exchange, I would want retina clearance first. It is unclear if the patient has had a PVD. I’d have an extensive discussion with them about the risk of retinal detachment. If the patient wants to proceed and has been thoroughly counseled with retina clearance, then I agree with Dr. Schoenberg’s recommendation of a Vivity blend.

Dr. Williamson: The retina piece is important. This patient is highly motivated, but what concerned me was that he was happy with his LASIK for years, and he’s still young. I’m more cautious in patients who have had that “wow” LASIK or ICL moment when you’re talking about lenses, especially if they’re still young. I went with bilateral custom lens replacement with toric monofocals. I didn’t opt for performing PRK because of the thin cornea, big astigmatic treatment, and early signs of nuclear sclerosis. I didn’t choose a toric ICL because the patient has a borderline cataract. I didn’t like the idea of multifocality because of prior large ablation and retina history. The patient was also not willing to tolerate halo or glare. He was very happy with the toric monofocals. 

ROUND 2 | CASE 2: 60-YEAR-OLD WITH METABOLIC SYNDROME WHO NEEDS HIGH-QUALITY NIGHT VISION AND SEEKS SPECTACLE INDEPENDENCE 

Dr. Williamson: This is a 60-year-old male who works as riverboat captain on the Mississippi River. He has a history of post-myopic LASIK 20 years ago, and states that he has been “back in bifocals” for several years. He is now seeing poorly and would like a solution to be spectacle independent again. He has a history of hypertension and insulin resistance, so-called metabolic syndrome. His slit lamp exam reveals some cortical changes likely related to his blood sugar, some trace nuclear sclerotic cataract, and LASIK flaps OU. His manifest refraction is +3.00sph 20/50 OD and +2.25sph 20/25 OS, Interestingly, he’s hyperopic now. He’s had myopic drift. He can no longer refract to 20/20. 

Figure 5 shows his tomography. He has some cylinder, 0.8 D OD and 0.25 D OS. His axial length doesn’t show a lot of astigmatism. 

Figure 5. Baseline tomography.

Dr. Williamson: He’s a riverboat captain and is often on the water at dawn. What factors do you consider when choosing an IOL in a patient with this profile? Would you offer diffractive optics in someone with poorly controlled diabetes or does it depend on HbA1c? Do you have a cutoff? For a patient who desires good night vision, would you not reach for a trifocal because of contrast issues? 

Dr. Nasser: For a patient like this, we need to know if the diabetes is well controlled, that the patient is healthy, and that they have a high likelihood of continuing to be healthy in the future. I don’t necessarily have a cutoff, but an HbA1c above 7 or 8 is a red flag. I’m concerned about the development of pathology in the future that would limit the optics of whatever lens I choose.

As far as dependency on night vision, it depends on the patient’s personality. I steer away from diffractive optics in patients who have high expectations and who are intolerant to halo and glare. As long as they are willing to compromise, I recommend an EDOF or monofocal. 

His VA is 20/50 OS, and the cataracts look similar. I don’t see anything on the cornea, so I’m questioning what’s going on there. I also need to know if his retina will be healthy long term. The LAL is a great option for a patient like this with an aberrated cornea because you’ll be able to nail the target afterward. 

Dr. Schoenberg: The red flag for me is the symmetric cataract and the symmetric topography. There’s a little bit more cylinder OD than OS, but it’s not substantially different. His VA is 20/50 in one eye and 20/25 in the other, but everything we see in the anterior segment looks similar. Macular and nerve OCTs are key to determining options. This patient is reportedly prediabetic with a little bit of insulin resistance. They might have a normal HbA1c. I’m very curious to see how the macular OCT looks, but I don’t want to limit his options out of fear. 

For patients who depend on quality vision at night, my IOL selection is also based on their personality. I have used diffractive optics with success in patients who fly recreationally or privately, but it’s important to show patients images or a simulator of what they might expect so they have an idea before you proceed.

Dr. Mueller: Obtaining macular OCTs and imaging on the optic nerves should be standard practice. We need to make sure that the retina is healthy. Regarding HbA1c, I don’t have a hard cutoff if someone is diabetic or prediabetic. I will offer them a diffractive IOL if that’s their best option, but it does involve a discussion. They can’t have any diabetic retinopathy for a diffractive IOL. If they have some diabetic retinopathy, there are other options that are more forgiving. Regarding night vision, the halo and glare from diffractive IOLs keep improving. They are more tolerable than they were 5 years ago. Technology is improving. 

Dr. Williamson: It’s rare for me to explant a trifocal or any diffractive optic because of halo and glare at night. The main reason I’ve seen is overall contrast sensitivity; some patients need that crispness. I’ve started offering patients who really desire a range of vision, like a long-haul truck driver or pilot, EDOF lenses. It’s interesting how that’s evolved over time because 8 or 9 years ago, you would never offer a pilot diffractive optics.  

Back to this patient, the retina was flat and healthy, and the patient did have good potential acuity in both eyes. Given that information, how might you take care of this patient who seems to be developing diabetes, has hypertension, metabolic syndrome, is overweight, and is very dependent on night vision because of his job? 

Dr. Schoenberg: For this patient, my primary recommendation is bilateral monofocals with femtosecond astigmatic keratotomies (AKs), distance target for both eyes, and reading glasses as needed. This patient has enough astigmatism OD that it’s likely to be visually significant, but it’s under the threshold of 0.9, where at age 52, I would think a toric lens would be appropriate. If he was adamant that he wanted more spectacle independence, then I’d suggest a trifocal. It seems patients obtain a crisper distance endpoint with modern trifocals than with EDOF lenses. We could also discuss LALs if he was amendable to that. 

Dr. Williamson: Dr. Schoenberg, any hesitation on femtosecond AKs given that the patient had LASIK? I worry about arcs in the cornea with LASIK flaps. I try go manual outside of the flap because I’m worried that I may cause epithelial ingrowth.¹⁰ Have you been successful with femtosecond AKs on top of old flaps for cataract surgery?

Dr. Schoenberg: I think it’s a great caution. I try to put my femtosecond AKs peripheral enough in those patients that they’re likely to be outside the flap, but it’s not always the case. If it’s a larger flap, I may not be able to reach that diameter. I don’t open femtosecond AKs. I think your concern about epithelial ingrowth is reasonable.

Dr. Nasser: If this patient is prediabetic and I don’t have concerns about his retinal health long-term, then a diffractive IOL is a good option as long as his personality fits. Depending on how that conversation goes, I’d start with offering a trifocal. But the patient needs to understand the limitations with night vision, the decrease in contrast, and potential for halos and glare. As long as he is good with those limitations, a trifocal, either the PanOptix or Odyssey, is my recommendation. Patients with aberrated corneas also do well with the LAL and mini-mono target. As far as femtosecond AKs go, I’ve performed plenty of AKs on postrefractive patients and they haven’t developed epithelial ingrowth. 

Dr. Mueller: I am also comfortable with offering a multifocal like the ClearView 3 in a patient with this profile. However, you have to have the right pupil measurement for that lens, about 2.7 mm, and it appears as though his pupils are smaller than that. For that reason, I’d select the LAL for this patient because it allows you to fine tune and adjust afterward. I’d use the LAL+ in his nondominant eye.

Dr. Williamson: I agree with all of your approaches, but I selected bilateral RayOne EMV. I did shoot for a -0.75 D target in the nondominant eye. He is very pleased with the lack of dysphotopsias and had a good refractive outcome. I’ve had success with this lens, particularly in hyperopes. 

ROUND 3 | CASE 4: 63-YEAR-OLD FEMALE WITH CATARACT AND HIGH ASTIGMATISM 

Dr. Williamson: Our next case is a 63-year-old female with a nuclear sclerotic cataract and poor vision. About 25 years ago, she had a 4-cut radial keratotomy (RK) OD and an 8-cut RK OS. She has known ectasia and cannot tolerate contact lenses. Although she doesn’t mind glasses, she prefers reduced spectacle dependence. Her right eye is dominant. Her glasses prescription is plano +2.75 x012 20/30- OD and +0.75 +1.50 x134 20/30- OS. She has more cylinder OD than she does OS. The manifest refraction is fairly similar (+1.75 +3.75 x018 20/25-2 OD and +1.25 +2.25 x150 20/25- OS). Her retinal imaging and baseline corneal topography is illustrated in Figures 6 and 7, depicting a classic crab claw pattern. Astigmatism is very high: 8.00 D OD and 6.70 D OS (Figure 8).

Figure 6. Baseline retinal imaging.  

Figure 7. Baseline corneal measurements.

Figure 8. Baseline biometer readings.

Dr. Williamson: Taking a wholistic view of all measurements (Table), what is the true astigmatism, and where is it? Patients with high levels of astigmatism are challenging to manage. This patient seeks improved vision, and I’m debating a next step because she has different cylinder levels at different magnitudes and somewhat different meridian.

Dr. Schoenberg: She has reasonable expectations with the preference not to wear contacts and be less dependent on glasses. She’s likely been living with high cylinder for a long time. Yes, the magnitude differs, but the axis of the cylinder is consistent between most devices (Table). What works in your favor is that despite that high astigmatism on the Pentacam and IOL Master, which is beyond the ability to correct with a toric IOL, she doesn’t refract all of that. This suggests that there may be some internal astigmatism, some neural adaptation, and some HOAs that are offsetting the measured cylinder that the IOL Master and Pentacam are picking up. 

I look at that topography and ask myself, does this look regular enough to correct to a reasonable endpoint with a toric IOL? And the meaning of “reasonable” shifts depending on patient goals. If the patient is a police officer who wants sharp 20/20 VA, then that patient will need a scleral lens. But in a patient who is 63-years-old and wants to reduce their glasses dependency, then a toric IOL would correct for that goal fine. 

Rahul S. Tonk, MD, MBA: How stable is this patient post-RK ectasia? There is a high likelihood that the magnitude and axis are shifting, therefore, even maximal astigmatism correction may not last. That said, most patients with progressive visual decline following RK understand and appreciate that. If we can make her happy now with a toric IOL, that would be my approach.

William F. Wiley, MD: How are her symptoms, and do they change through the day? Does she have diurnal fluctuation? Is the ectasia with RK still progressing? If you’re going to use a lens with advanced technology, you need to control the progression of that irregular cornea. I’d consider CXL. The problem with that approach in this patient population is you tend to worsen their spectacle prescription because it causes further flattening. 

You’ll need to prepare the patient for this and explain that they have a condition that is going to worsen over time. Our course of action will make that condition worse in the short term but stabilize the cornea from progressively worsening. Furthermore, with a subsequent procedure, we can recorrect the induced hyperopia that’s with the lens. 

We can proceed with a monofocal toric lens to correct the sphere and cylinder, but I want to know if she is bothered by glare at night or other symptoms of irregular astigmatism that can’t be corrected by a monofocal IOL. Is she having aberrations from the RK? I’d consider the IC-8 Apthera lens, which may reduce some of her HOAs. If she’s looking for reduced spectacle independence and to correct her irregular astigmatism, you could use an IC-8 plus LAL in the sulcus. That will be an expensive option, but it should be presented to her. With all that said, if she can wear scleral lenses, that’s the easy option.

Dr. Schoenberg: LAL in the sulcus is a clever way to achieve her goals. I was going to suggest CXL to her first and then use a toric lens. Most of the measurements agree. I’m not worried that the magnitude of the node in the refraction is lower than those huge numbers we’re seeing. I would take what the biometer tells me, and round it down to avoid overcorrecting. I would tell the patient that the toric lens is not intended to make her free of glasses, it’s intended to make her prescription simple, lightweight, and easier to manage. 

However, if the patient said she’s never been happy with her post-RK vision, then that is a different conversation. In that case, I would perform CXL and topography-guided PRK as my first prep steps to address her cornea. Then I would think about whether we’re going to use a toric lens, correct the astigmatism, or simulate, either with a pinhole outside or pilocarpine inside the eye. What might you achieve with the IC-8 Apthera? It could be beneficial for those HOAs, but it won’t do enough to correct her astigmatism. 

There’s no wrong answer. It’s all about listening to how long a journey she wants to go on and how much she’s willing to invest in terms of time and money. 

Dr. Williamson: We selected bilateral max power EnVista toric IOLs OU. Two-weeks postoperatively, her VA was 20/30 OU, with some residual cylinder (-0.50 +1.50 x014 and -2.75 +1.00 x165 OS). I’m now planning an LAL piggyback OS. Would I have been better off CXL this patient before cataract surgery? 

Dr. Tonk: I don’t think the science is as clear with CXL post-RK ectasia as compared with keratoconus or post-LASIK ectasia. Although there may be some benefit, you have to decide if the juice is worth the squeeze. You would have to delay cataract surgery for months to years to judge progression and stability before and after CXL, not to mention destabilizing this patient’s ocular surface disease. I’m not convinced CXL is the answer, and it would be practical and reasonable to proceed directly to cataract surgery with toric IOLs as long as the patient’s expectations are appropriate.

ROUND 3 | CASE 5: 44-YEAR-OLD WITH LEGACY ICL AND EARLY CATARACT

Dr. Williamson: Our next case is a 44-year-old female who had an implantable collamer lens (ICL) 20 years ago OD. They kept her nearsighted OS so she “wouldn’t lose near vision later in life.” Now, she’s presenting with poor vision OD and wants to correct her vision OU. With correction, her VA is 20/40 -2 OD and 20/25 OS. She’s very nearsighted OS. The exam shows anterior subcapsular cataracts (ASC) and cortical changes OD. Her topography (Figure 9) is unremarkable, but shows some astigmatism OD. Everything looks fairly normal. Dr. Wiley, how do you approach legacy ICL? This person is young and having some early cataract formation. Are you going to observe this person or offer surgery? 

Figure 9. Baseline imaging.

Dr. Wiley: I’m often surprised by how well these patients tolerate ASC. When I ask if it’s bothering them, they often don’t know it’s there. In those cases, I’ll monitor them. If we need to address the cataract, thankfully, she hasn’t had corneal surgery, which keeps multiple lens options available. She could benefit from a multifocal lens to help keep a full range of vision OD. I would consider the Odyssey multifocal. For the left eye that is still myopic, I’d select the EVO ICL. 

Dr. Schoenberg: The patient is complaining of poor vision OD, so we need to address that. I’d select a full-range lens, like the Odyssey or the PanOptix. Both are great choices. I would use the toric variant, based on the biometry. I’d start with the right eye, treating to plano. She’s used to a lot of anisometropia because she’s been a -7 OS for 20 years. After cataract surgery OD, I would let her live with that for a few weeks to see if she adapts. If she doesn’t tolerate blended vision, then surgery is the next step. But I’m going to be counseling her hard to lean toward ICL, which is what I’d prefer to do in a 44-year-old, though she may want a refractive lens exchange with a matching multifocal lens.

Dr. Tonk: What jumps out at me is that she elected to maintain such high myopia and extreme monovision OS all these years. I’m curious whether she used this eye as a “magnifier” for some unique occupational or recreational need. 

In the scenario that the patient likes or wants to preserve her unique monovision, then I would place an LAL or monofocal toric in the right eye targeted to plano, and I would pursue an ICL or laser vision correction OS with a target determined by a contact lens trial. For distance OD, this preserves excellent contrast and quality vision. For monovision near OS, this avoids the risks of lens-based surgery in a high myope, and also makes use of her residual accommodation for maximal near vision.

If she doesn’t care for her monovision, then I’d pursue a diffractive multifocal or EDOF OD and ICL or LVC OS targeted to plano, with the caveat that she may need glasses for very fine print.

Dr. Williamson: I used an Odyssey toric OD and an EVO ICL OS. It seems like all of us were thinking about phakic eye wells. Just because you can nail -7.00 D with a laser, doesn’t mean you have to do this. Although that is a good choice, I’ve found most patients are not experiencing a cataract formation with the EVO even though they had a cataract develop from legacy ICL. 

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