Eyeworld

52 | EYEWORLD | WINTER 2026 R EFRACTIVE References 1. Fernández J, et al. Global con- sensus on the evidence-based functional classification of simul- taneous vision IOLs. J Cataract Refract Surg. 2026;52:219–222. 2. Woodward MA, et al. Dissatis- faction after multifocal intraocu- lar lens implantation. J Cataract Refract Surg. 2009;35:992–997. 3. Tuuminen R, Jeon S. Associ- ation of ocular comorbidities on long-term patient-reported outcome measures after multifocal intraocular lens implantation. Am J Ophthalmol. 2026;281:384–394. by Karolinne Rocha, MD, PhD Refractive Editor T he first lessons I teach the medical students, residents, and fellows I work with are to learn the technology and understand the optics and clinical per- formance of all IOLs on the market and in the pipeline so that you're able to match the best solution with the patient's needs. The new classification system—the result of the Functional Vision Working Group and detailed in the Journal of Cataract & Refractive Surgery 1 —makes learning easier with descrip- tive language and definitions measuring clinical performance across distance, intermediate, and near vision, instead of taking into account pure- ly optic designs and optics bench data. We now have the terminology of depth of field (DOFi), ranging from Partial, which includes subcategories of Narrowed, Enhanced, and Extended, to Full, which includes subcat- egories of Steep, Smooth, and Continuous. "When the stars align: a global consensus on classifying IOLs by depth of field" details the efforts of the Working Group with help from Joaquín Fernández, MD, PhD, and Douglas Koch, MD. Dr. Fernández, who is also the first author on the consensus paper, elegantly puts it into the broader context: "Its most important contri- bution is that this language is linked to scientific evidence and to measurable clinical outcomes, so that functional classification terms we use ac- tually represent the visual performance patients can expect." Using words linked with the visual perfor- mance that patients can expect will also help in setting patient expectations, a crucial theme of "When the stars don't align: managing the unhappy patient." In it, my colleagues Kendall Donaldson, MD, MS, Parag Majmudar, MD, and William Wiley, MD, provide insights into the sys- tems they have set up for postoperative patient dissatisfaction. For my approach, I review the checklist of possible causes in order to have a satisfying an- swer ready before walking into the exam room. My checklist includes: 1) residual refractive error, 2) ocular surface disease, 3) posterior capsule opacification (PCO), 4) retinal patholo- gy, including macular OCT imaging, 5) irregular astigmatism on the corneal topography/tomog- raphy, and 6) dilated exam to look for vitreous floaters. 2,3 If everything is normal and the patient is still having significant issues with dysphotopsias at night, this points to neuroadaptation being the cause. However, studies have found this to be the case in only about 7% of patients or less. 2 One of the items my colleagues also men- tion is deploying a trial lens in clinic. I utilize this tool for my myopic patients to demonstrate the effect of correcting distance vision on unaid- ed reading, and I use the patient's reaction to guide the IOL selection. Virtual reality headsets also do an excellent job of matching the tech- nology and demonstrating postoperative visual expectations to patients. As we seek to give patients excellent re- sults, shared language communicating what is possible in our rapidly changing technological environment is a must. Thank you to my col- leagues for their collective work. Our rapidly changing technological environment Kevin M. Miller, MD, EyeWorld Cataract Editorial Board member, commented on new tools, techniques, and challenges in anterior segment surgery: "The things I would most like to see in the coming decade are: 1) a truly accommoda- tive IOL, and 2) IOLs that are continuously adjustable over the life of a patient. The adjustments should include sphere, cylinder, high order aberrations, and focality (being able to add or subtract the number of focal points and energy distribution in a diffrac- tive IOL). A combination of these would be most ideal and would eliminate the need for multifocality." to the MOON and BACK

• Cover