Eyeworld

70 | EYEWORLD | SPRING 2025 R EFRACTIVE by Liz Hillman Editorial Co-Director About the physicians John Berdahl, MD Vance Thompson Vision Sioux Falls, South Dakota Lance Kugler, MD Kugler Vision Omaha, Nebraska P atients who opt to have an advanced- technology IOL (whether it be toric or presbyopia correcting) tend to have higher expectations for their postop vision, and as such, most surgeons pro- ficient with these lenses are prepared to provide enhancements via laser vision correction, IOL rotation, or IOL exchange, when needed. So while some level of enhancements are expected with refractive cataract surgery, what is an "acceptable" enhancement rate? Lance Kugler, MD, first pointed out that we have to agree upon what the criteria ought to be for enhancements. "If we can agree that achieving a spherical equivalent within 0.50 D, with 0.50 D or less of cylinder, is the goal for multifocal IOL patients, the data is quite clear," Dr. Kugler said. "Most studies that have looked at IOL calculation accuracy have determined that modern formu- las can deliver around 80% within 0.50 D of the intended target. The best datasets published are between 90–92%. That means that in the best possible scenario, the best we can hope for is an 8–10% enhancement rate. Informal surveys of experienced refractive/IOL surgeons sug- gest that 10–12% enhancement rate is typical in practices that are tracking these outcomes closely." John Berdahl, MD, said the range is from 2.5–12.5%. "Like anything in medicine, there's judg- ment on risk versus benefit. But in our practice, we are very willing to take someone from good to great with even a small correction," he said. Enhancement stigma? Dr. Kugler added that he doesn't think it's possi- ble to have a less than 10% enhancement rate, per published data. "Certainly a surgeon could decide to have a lower enhancement rate by choosing to not offer enhancements, but that simply means that 8–10% of their patents are not seeing as well as they should be and are likely unhappy," he said. When asked whether there might be a "stigma" around doing enhancements that could have some surgeons avoiding them, Dr. Kugler said yes. "I think surgeons often think that an enhancement means failure. Patients may think that, too, if they are not properly counseled. In our practice, we tell every patient that they should expect to require an enhancement and that it is a normal part of the process. That way, when needed, they do not interpret it to be a failure," he said. "Our job is not to protect our ego; our job is to get the best possible outcome for the patient," Dr. Berdahl said. He said that enhance- ment rates vary from surgeon to surgeon based on their personal judgment, technology avail- able to them, experience with refractive sur- gery, and use of modern formulas and cataract surgery techniques. However, predicting the future is easy, but being right is hard, he continued. "There are some patients who don't fall into the exact parameters for IOL calculations or even aber- rometry. And there are some patients who don't tolerate a new optical system that includes multifocality or extended depth of focus," Dr. Berdahl said. "Our job is to take the patient where they're at and get them to the best place possible. "Now, surgeons are humans, too, so often- times we think of an IOL exchange or a LASIK enhancement as a failure or that we missed. It only becomes a failure when you quit trying to solve the problem," he said. "My message to pa- tients if they have an eye that's not pristine be- fore surgery is that they have a higher chance of needing an IOL exchange, and if they're willing to take the risk of a trifocal IOL in exchange for the vision they want for the rest of their lives, I'm willing to take that risk alongside them as long as we both think that it's not a failure if we need to take that lens out. Similarly, I tell pa- tients that 1 out of 10 or less patients will need a laser enhancement after surgery. We include that in the price because we know that it's going to happen to some patients because our predic- tive capability isn't perfect." Enhancement considerations Dr. Kugler begins to consider an enhancement for the patient when there is treatable refractive error that is decreasing visual quality. "If the patient is happy with their less-than-optimal vision, sometimes they choose to forego the additional step, but we make it Enhancement rates: what's acceptable and expected?

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