Eyeworld

60 | EYEWORLD | FALL 2026 R EFRACTIVE Relevant disclosures Carones: Alcon, Johnson & Johnson Vision Rocha: Bausch + Lomb, BVI Medical, Johnson & Johnson Vision, STAAR Surgical newer diffractive full vision range lenses shows that they have a higher tolerance for residual refractive error. Dr. Rocha and Dr. Borges think that the tolerance also depends on the depth of focus curves, stating, "A broader defocus curve and increased contrast sensitivity of the new full DOFi lenses may be one explanation for our clinical findings." Older lenses, for example the Synergy IOL (Johnson & Johnson Vision), had a steep decline, especially for patients who ended up with residual myopia. From all the categories of lenses examined, Dr. Rocha and Dr. Borges said the enhanced monofocal category performed the best. The enhanced monofocal IOL provided the greatest tolerance to induced astigmatism, especially under oblique and ATR orientations. 2,3 "Enhancement rates are now very low because even if patients have small amounts of residual astigmatism postoperatively, they're happy," Dr. Rocha said. "We're not seeing a sig- nificant decline in distance visual acuity." 2 Dr. Rocha also noted published data from Robert Ang, MD, on the IC-8 Apthera (Bausch + Lomb) small aperture lens. 4 This lens is an ex- tended depth of field IOL approved for up to 1.5 D of astigmatism, and she said it has perhaps the highest tolerance to defocus. Dr. Rocha said that Victoria Moreira Fer- nandes, MD, and Camilla Crema, MD, other fellows of hers, are also studying newer genera- tion lenses, like the diffractive apodized enVista Envy (Bausch + Lomb), the next generation trifocal PanOptix Pro (Alcon), the new refrac- tive extended depth of field PureSee (Johnson & Johnson Vision), and in the near future the enhanced monofocal Clareon TruPlus (Alcon). Dr. Rocha added that it's always import- ant to do a careful preoperative assessment. Treating dry eye, evaluating the topography and biometry measurements, and ruling out retinal pathology and other ocular diseases are important steps. "Dry eye disease and irregular tear film are highly prevalent in aging patients, and some of those lenses may perform well," but you still need to put in the work. Despite the increased tolerance to astigmatism with newer generation IOLs, Dr. Rocha recommends full attempted astigmatism correction at time of surgery whenever possible to achieve patients' goals. She said that future studies in this area may look at how lenses can perform in patients with mild glaucoma, ERM, etc. "Subsequent research must examine toler- ance not just in regulated optical bench tests but also in extensive, real-world clinical series where variability is inevitable. I am curious to see how these novel lenses work in typical postoperative situations, such as persistent astigmatism or small myopic/hyperopic offsets," he said. "I think this kind of information will be helpful in enhancing patient counseling and the criteria for choosing different types of IOLs." Dr. Carones also stressed that tolerance to refractive error is an important but frequent- ly overlooked element in choosing an IOL. "Surgeons naturally focus on making sure that patients can see clearly and don't need glass- es, but patients measure success by how clear and stable their everyday vision is. A lens that is more forgiving of little mistakes may make patients happier overall," he said. Karolinne Rocha, MD, PhD, has also studied tolerance to simulated astigmatism. Dr. Rocha and her fellow Hugo Tardin Fragoso Borges, MD, shared some of what they learned from research on this topic. Historically, we know that patients with standard monofocal lenses can tolerate more residual refractive error, Dr. Rocha said; astigmatism exceeding 0.50 D can affect the visual acuity and quality of vision when dealing with diffractive optics. For the unhappy presbyopia-correcting IOL patient, Dr. Rocha said common complaints are from dry eyes, PCO, residual refractive error, or vitreous floaters, among other issues. Their study looked at different lens cat- egories: the standard monofocal, enhanced monofocal, diffractive extended DOFi, and full range of vision (full DOFi) lenses. 2 The research simulated with-the-rule (WTR), oblique, and against-the-rule (ATR) astigmatism across four different IOL models on the same platform. Dr. Rocha and Dr. Borges confirmed that patients tolerated more WTR astigmatism. The study compared the tolerance to induced astigmatism up to 2.0 D in different orientations. Oblique and ATR astigmatism had a greater effect on visual function in all IOL groups. Dr. Rocha said that the newer generation, full range of vision lenses (Odyssey, Johnson & Johnson Vision) performed better than expect- ed. In some orientations, they were even better than the diffractive extended depth of field lens (Symfony OptiBlue, Johnson & John- son Vision). Dr. Rocha said that the quality of Contact Carones: fcarones@carones.com Rocha: karolinnemaia@gmail.com continued from page 59

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