Eyeworld

WINTER 2026 | EYEWORLD | 59 R sitting across from him, the expectation discon- nect already happened months earlier. "A common version of this is a low myope, minus one or minus two, who has spent a life- time pulling off her glasses to read," Dr. Wiley explained. "Now she has a cataract. We talk through lens options, she says she just wants to see distance well, and we deliver exactly that— great uncorrected distance vision. Then she comes back unhappy because her near vision, the thing she never asked me to protect because she did not realize it was at risk, is gone. I probably did explain it ... and [she] simply did not hear the part about losing her near vision because in her mind, she already had good near vision and did not think there was anything to lose." In situations like this, Dr. Wiley said he has gotten more aggressive with contact lens trials. "Explanation is one thing. Demonstration is another. … That trial is doing work that no consent conversation can do on its own," he explained. "The same logic applies after the fact. If a patient comes back unhappy and I suspect the miss might actually be tolerable, or even beneficial, once they get used to it, I will use a contact lens trial again before agreeing to a second surgery. I have had patients realize, once we simulate correcting the eye they think is the problem, that they were relying on that eye more than they knew." Dr. Donaldson also finds a trial frame or contact lens trial helpful. "If correcting the refractive error produces the quality of vision the patient wants, that strongly supports a refractive solution," she said. "If it does not, I continue looking for another cause rather than simply treating the numbers. The tomography lets me know if the patient may be a candidate for a corneal laser refractive procedure, and the iTrace ray tracing technology [Tracey Technolo- gies] particularly helps differentiate whether the vision problem is more related to the cornea or internal structures (the lens or vitreous)." When to enhance or exchange Before he decides that an enhancement or IOL exchange is necessary, Dr. Wiley rules out ocular surface issues. Dryness can masquerade as a refractive miss. While a true refractive error remains stable, visual issues caused by dryness tend to fluctuate, with vision being sharp in the morning and blurry by the afternoon. "Once I point that pattern out, patients generally recog- nize it in themselves even when they insist their eyes do not feel dry," he said. Dr. Majmudar emphasized that with careful preop planning and meticulous surgery, the need for a refractive enhancement is low. Some procedures inherently have a higher rate of regression than others, which at times actually benefits the patient. However, if the regression is visually signif- icant and stable, he thinks retreatment can be indicated. "If a patient had LASIK within a short period of time (usually <1 year), the flap can be easily lifted," he said of refractive surgery patients who might need an enhancement. "Pa- tients should be warned about possible compli- cations such as epithelial ingrowth, which are more likely after a flap has been relifted. If the patient initially had PRK, SMILE, or LASIK in the remote past, often PRK is the best approach, but the patient may be at a slightly higher risk of corneal haze afterward. The case of retreat- ment after SMILE is unique as there is a method to convert the cap of SMILE into a flap and proceed by treating under the new flap." Dr. Majmudar added that he would counsel a pa- tient against retreatment if the refractive error is low (less than 0.5 D) or if the patient has benefits, such as improved near vision, from the limited residual refractive error. continued on page 60 Dr. Majmudar said careful ophthalmic examination is critical when assessing patients who are not satisfied with refractive outcomes following corneal or lens-based surgery. Source: Parag Majmudar, MD

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