Eyeworld

SPRING 2026 | EYEWORLD | 75 R Contact Donnenfeld: ericdonnenfeld@gmail.com Tonk: rahul.tonk@gmail.com Relevant disclosures Donnenfeld: Alcon, Bausch + Lomb, Johnson & Johnson Vision Tonk: None 30% with a multifocal lens," he said. Addition- ally, as EDOF lenses become better—with new options expected this year—he thinks there will be more of an uptick in use of these options. "I think we'll be doing more EDOF toric lenses as well," he said, adding that it's an easy conversion to go from a multifocal to an EDOF lens. "They don't get quite as much reading, but their quality of vision is much better at distance." Postoperatively, when you've done cataract surgery and there is still residual cylinder, Dr. Donnenfeld said a slit lamp limbal relaxing incision can be a good option to manage these patients. Dr. Tonk said he views this choice between lens options as a hierarchy, with the base being ocular health. "If the macula, optic nerve, or oc- ular surface are compromised, I steer away from presbyopia-correcting options," he said. "If the ocular health is pristine, we move to the next layer: lifestyle. I ask myself, 'Would this patient have a richer life without the burden of glass- es and contacts? What are their specific visual tasks, and how do they use their eyes?' The final layer is preference, specifically their willing- ness to accept potential optical imperfections or photic phenomena in exchange for spectacle independence." Dr. Tonk said that certain levels of astig- matism make certain lenses more desirable. Presbyopia-correcting IOLs (especially diffrac- tive multifocals) are less forgiving of residual astigmatism than monofocals. "Even small amounts of residual cylinder can significantly degrade the modulation transfer function and image quality in a multifocal eye," he said. Dr. Tonk added that if a patient has irregu- lar astigmatism or a level of cylinder where he cannot guarantee a residual <0.50 D, he will generally avoid diffractive PC IOLs. "In these cases, the LAL is an excellent alternative, or I stick to a monofocal toric to ensure quality of vision over range," he said. said. "About 50% of patients have 0.75 D or more cylinder, so I think toric lenses are the entry point for most doctors in doing refractive cataract surgery. I often get asked, 'How do you get started in refractive cataract surgery?' and I say, 'Don't start with a multifocal IOL; start with the toric IOL.' That's the low-hanging fruit for managing these patients, and I think we should do a lot more of that." There may be some cases where you're unsure how to proceed, predominantly patients who are post-LASIK and have cylinder or those with underlying problems that make it less like- ly that you're going to hit the nail on the head. You can always manage cylinder with an LAL. That's a good way of managing cylinder when you don't feel confident in a toric IOL, he said. Dr. Tonk also prefers to use toric IOLs when possible, and he also likes to treat all astigma- tism. However, he noted that a "gap" exists in current inventory because most platforms start at around 1.25–1.50 D at the IOL plane. "Conse- quently, I generally select toric IOLs only when corneal astigmatism exceeds 0.75 D (against- the-rule) or 1.0–1.25 D (with-the-rule)." For patients falling into this gap, where a toric is too powerful but the astigmatism re- mains visually significant, Dr. Tonk said he relies on FSAK or the LAL. Toric IOLs, he said, offer the highest pre- dictability and stability for significant astigma- tism, but they are fixed. "If the effective lens position varies or the lens rotates, the result is compromised." Meanwhile, he said that corneal incisions (FSAK/LRI) are less invasive in terms of hard- ware but less predictable for higher magni- tudes of correction. "They also carry a risk of regression over time and can exacerbate dry eye symptoms by severing corneal nerves." Dr. Tonk said the LAL has become a "prob- lem solver" for predictability. "It allows us to treat residual refractive error postoperatively, essentially eliminating the variables of effective lens position and healing response." The decision on which lens to choose is often more of an issue of the patient's visual request rather than the cylinder, Dr. Donnenfeld said. "I do about 70% of my cases with a mono- focal or a monofocal plus lens, and I do about

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