Eyeworld

SPRING 2025 | EYEWORLD | 71 R Contact Berdahl: john.berdahl@ vancethompsonvision.com Kugler: lkugler@kuglervision.com Reference 1. Rohlf D, et al. Outcomes of LASIK vs PRK enhancement in eyes with prior cataract surgery. J Cataract Refract Surg. 2023;49:62–68. Relevant disclosures Berdahl: Alcon, Bausch + Lomb, Johnson & Johnson Vision, Zeiss Kugler: Johnson & Johnson Vision, Zeiss very clear that we recommend it in order to maximize vision quality," Dr. Kugler said. As with any refractive surgery, ocular sur- face management before and after is critical, Dr. Kugler continued. Treating the ocular surface can decrease the need for enhancement or at least changes the measurements. Dr. Berdahl said he knows an enhancement is on the table if there is 1 D of cylinder or 0.5 D or more of a refractive miss postop. Smaller refractive misses are more of a judgment call. In those latter cases, he relies on a few things. "One is the topography, two is epithelial mapping, three is an assessment of dryness, and four is the OCT. The final common pathway is a pair of temporary glasses; if that patient wears a pair of temporary glasses with that prescription and they say, 'This is how I want to see,' I know that a laser enhancement is the move," he said. When it comes to the epithelium, Dr. Berdahl said one needs to make sure that it's uniform, clear, and not EBMD, even subclinical. Other pearls for enhancements that Dr. Berdahl offered are to intervene early with a temporary pair of glasses for unhappy patients. "If a patient's unhappy at 1 week and they have refractive error, I give a temporary pair of glasses very early for two reasons. One is an un- happy patient is often just a scared patient, and if you can show them that they can see well, they'll go from being scared to understanding that we've got a solution for them. Number two, I know that they don't have PCO yet. So if they develop early PCO, I know that if the glasses fixed their vision, it's not the PCO that came later and I can YAG them and do their laser enhancement." When he determines an enhancement is needed, Dr. Berdahl said research has found LASIK to be more predictable than PRK. 1 "The most likely reason for this is that irregular epi- thelium of older patients is common. So when you do a PRK, you wipe off that epithelium and it grows back in a different, smoother configura- tion, which is nice, however, it's less predictable for the refraction, so we usually do LASIK, if we can," he said. Forward thinking When offering advanced-technology IOLs, surgeons must have an enhancement strategy, according to Dr. Kugler. This means not only considering broader access to enhancement tools but also each individual patient's possible future scenarios. "If a future enhancement is not possible due to abnormal corneas or other comorbidity, a multifocal IOL or IOL requiring a high pre- cision outcome should be avoided," Dr. Kugler said. "The Light Adjustable Lens [LAL, RxSight] is often a good option in these patients. This is particularly true of post-refractive patients who are difficult to enhance after IOL procedures." If surgeons do not have access to LASIK as a post-refractive cataract surgery enhancement tool, Dr. Kugler suggested partnering with a local LASIK surgeon for these cases as a poten- tial strategy. He again mentioned the LAL as a possible strategy instead of LASIK. "Some surgeons use IOL exchange as an enhancement tool, but doing so does not pro- duce the same level of precision in outcomes, particularly for low amounts of astigmatism," Dr. Kugler added. Overall, Dr. Kugler thinks that enhance- ments are among the biggest barriers to adop- tion of advanced-technology IOLs in cataract practices. "Lack of access to enhancements, or lack of planning for enhancements, is one of the big- gest if not the biggest factor to the low adoption rate of premium IOLs," he said. Blake Williamson, MD, EyeWorld Refractive Editorial Board member, shared what he is excited for at the ASCRS Annual Meeting: "I'm most looking forward to learning about surgeons' experiences with new IOLs, such as the enVista Envy [Bausch + Lomb] and RayOne EMV [Rayner]. I'm also looking forward to hearing about how to manage LAL [RxSight] complications, such as visual disturbance post lock-in." ASCRS ANNUAL MEETING P R E V I E W

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