Eyeworld

56 | EYEWORLD | FALL 2026 R EFRACTIVE strategy—can be beneficial, it does not replace the value of lenses that deliver range of vision immediately and predictably. Beeran Meghpa- ra, MD, said he tries to tease out of patients what their refractive goals are with surgery, and he matches the IOL that could best meet these goals based on their ocular anatomy and conditions. Dr. Meghpara said when a patient is inter- ested in advanced-technology cataract surgery and spectacle independence, he'll start with a trifocal discussion (if they're a candidate) because these give the biggest range of vision. Based on feedback during this discussion and patient candidacy, he'll direct the conversation away from trifocals to lenses like the LAL, EDOF, or monofocals, as needed. Just because the LAL ensures accuracy in the notoriously difficult post-refractive patient doesn't mean all those patients are not candi- dates for a multifocal IOL. "Before, it was not even on the table for me," Dr. Meghpara said of using older generation trifocal IOLs in post-re- fractive patients. The key is that the patient has to be a good candidate. For Dr. Meghpara, this means having regular topography and a more modern ablation. "LASIK in the 90s was different than LASIK in the 2000s, which is different than LASIK performed in the last 5–10 years. … These more modern treatments do better with a trifocal IOL compared to someone who had LASIK in the 90s," he said, adding that he looks at the abla- tion pattern and considers the patient's expec- tations. "Are they a candidate for and willing to get laser vision correction touch-ups?" he said, adding that sometimes post-LASIK patients are already more tolerant of glare and halos, though trifocals could make them worse. "Now, the flip side is, if they don't meet my criteria, I will give them the LAL as an option, but with the caveat that it's not the same thing [as a full range of vi- sion IOL], but it may be more forgiving in their specific circumstance." Improvements in full range of vision optics have influenced patient candidacy in Dr. Koch's opinion as well. He addressed how newer gen- eration trifocal and EDOF IOLs have "brought things to a completely different level in terms of quality of vision and predictability in terms of dysphotopsias." With trifocals, Dr. Koch said his patients are tolerating glare and positive dys- photopsias more than they had before. He also said some modern IOLs have a larger refractive landing zone, making it less impactful if the power is a little off. He specifically mentioned the TECNIS PureSee IOL (Johnson & Johnson Vision), which he described as "providing a nice range of distance with a little bit of near and almost no dysphotopsias," and the TECNIS Odyssey (Johnson & Johnson Vision). In general, Dr. Koch emphasized that "a full depth of field IOL is very reasonable if the cornea has good quality optics, as determined by topography and tomography centrally," even if it's had prior refractive surgery. continued from page 55 Contact Koch: dkoch@bcm.edu McKee: mckeeonline@mac.com Meghpara: bmeghpara@willseye.org Relevant disclosures Koch: Johnson & Johnson Vision, Perfect Lens, VirtuaLens, Zeiss McKee: JelliSee Meghpara: Bausch + Lomb, Johnson & Johnson Vision, RxSight John Hovanesian, MD, EyeWorld Cornea Editorial Board member, reflected on how ophthalmology is refining, combining, and reimagining modern care: "In May 2005 when CMS allowed Medicare patients to choose premium lenses and pay the cost difference, ophthalmology was reborn. Prior to that date, we could not offer premium lenses to Medicare patients because the cost of the lens had to be paid from the global surgery center/hospital fee, which was about $1,000, not much more than the cost of the lens itself. The CMS rul- ing allowed balance billing for these lenses (and later for femtosecond correction of astigmatism). I thought the use of ad- vanced-technology lenses would explode, and I was wrong. Now, 21 years later, we are seeing doctors across the country embrace these lenses more readily. This has elevated the level of service we offer to all cataract patients, regardless of the lenses they choose, because we are now communicat- ing more openly about each patient's visual goals for surgery. We are thinking more carefully about treating dry eye. We more carefully evaluate for hidden comorbidities, so we can properly counsel patients." REFRESH. REFINE. REWIND.

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