Issuu

SUPPLEMENT October 2026 MediaMICE.com

PRECISION PERSONALIZATION

FACULTY MARJAN FARID, MD Professor of Ophthalmology Director of Cornea, Cataract and Refractive Surgery Gavin Herbert Eye Institute, UC-Irvine, California

WILLIAM K. CHRISTIAN, MD Medical Director The Vanguard Eye Institute Santa Monica, California

NIRAJ DESAI, MD Co-Chief Medical Officer Milan Eye Center, Georgia

SUMITRA S. KHANDELWAL, MD Professor of Ophthalmology Cornea, Cataract and Refractive Surgery Baylor College of Medicine - Cullen Eye Institute, Houston

JULIE SCHALLHORN, MD Professor of Ophthalmology Rose B. Williams Endowed in Cornea Research Department of Ophthalmology Francis I. Proctor Foundation for Research in Ophthalmology University of California, San Francisco

GEORGE O. WARING IV, MD Medical Director and Founder Waring Vision Institute Mount Pleasant, South Carolina

ACTIVITY DESCRIPTION This expert consensus statement examines the modern refractive IOL portfolio and the Functional Vision Framework, offering guidance on patient selection, diagnostics, and shared decision-making to help surgeons match presbyopia-correcting lens technology to each patient’s visual goals.

TARGET AUDIENCE This accredited educational activity is designed for ophthalmologists.

LEARNING OBJECTIVES •

Apply a structured, patient-centered framework aligned with the Global Functional Classification of IOLs to match refractive IOL technology to individual visual goals, lifestyle demands and ocular characteristics.

•

Integrate advanced diagnostic data into surgical planning to enhance refractive accuracy and minimize postoperative surprises in refractive cataract surgery.

•

Differentiate contemporary refractive IOL design strategies and implement a diverse portfolio of refractive IOL designs to address a wider array of patient needs, expanding the reach and clinical success of the refractive practice.

•

Implement structured patient communication strategies to align expectations, discuss quality-of-vision trade-offs, and strengthen informed consent in refractive IOL counseling.

GRANT SUPPORT STATEMENT This activity is supported by an unrestricted educational grant from Johnson & Johnson Surgical Vision, Inc.

ACCREDITATION STATEMENT

Axiom Ophthalmic, LLC is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

OCTOBER 2026

CREDIT DESIGNATION STATEMENT Axiom Ophthalmic, LLC designates this enduring activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

TO OBTAIN CREDIT To obtain credit for this activity, log in to the Axiom Learning Center and go to https://www.axiomlearningcenter.com/courses-page/ course/precision-personalization-refractive-iol-technology or scan the QR code with your smartphone's camera. Once you’re logged into the course, you must complete the pre-test, view the activity, successfully pass the post-test and complete the evaluation. Only candidates with a passing score of at least 70% earn CE credit. Candidates have the opportunity to retake the post-test until a passing score is achieved. The course credit certificate will appear in the certificates section of your account automatically upon successful completion of the course. For any additional questions about obtaining credit, please email info@axiomophthalmic.com.

DISCLOSURE POLICY It is the policy of Axiom Ophthalmic that faculty and other individuals in a position to control content of this activity disclose all financial relationships with ACCME defined ineligible companies within the past 24 months. Axiom Ophthalmic has policies in place that have identified relevant relationships and mitigated any real or apparent conflicts of interest prior to this educational activity.

DISCLOSURES Marjan Farid, MD, Program Director, has the following financial relationships: Consultant/ Advisor: AbbVie, Alcon, Allergan, Aurion, Bausch + Lomb, BioTissue, BVI, Carl Zeiss Meditec, CorneaGen, Glaukos, Harrow, Johnson & Johnson Vision, Orasis, Sight Sciences, Stuart, Sun Ophthalmics, Tarsus, Viatris. William K. Christian, MD, Faculty, has the following financial relationships: Consultant: Johnson & Johnson Vision. Niraj Desai, MD, Faculty, has the following financial relationships: Consultant/Speaker: Johnson & Johnson Vision.

CAKE

Sumitra S. Khandelwal, MD, Faculty, has the following financial relationships: Consultant: Bausch + Lomb, Carl Zeiss Meditec, Johnson & Johnson Vision. Julie Schallhorn, MD, Faculty, has the following financial relationships: Consultant: Carl Zeiss Meditec, ForSight V6, Glaukos, JelliSee, Johnson & Johnson Vision, Journey 1, NeuroTrigger, Novus Vision, OCULUS and Tarsus. George O. Waring IV, MD, Faculty, has the following financial relationships: Consultant: ACE Vision, AcuFocus, Alcon, Allergan, Atia Vision, Bausch + Lomb, Carl Zeiss Meditec, Centricity Vision, GlassesOff, Glaukos, iTrace, Ivantis, Johnson & Johnson Vision, Orasis, Perfect Lens, ReFocus, Reichert, ScienceBased Health, and SRD Vision; Investigator: Avedro; Investor: AcuFocus; Medical Advisory Board: ACE Vision, AcuFocus, Alcon, Allotex, Dompé, EyePoint, Glasses Off, Johnson & Johnson Vision, Novartis, Omega Ophthalmics, Omeros, Optoquest, Perfect Lens, ScienceBased Health, Shire, and Sight Sciences; Medical Monitor: Avedro; Principal Investigator: Allergan; Scientific Advisory Board: Avedro, Bausch + Lomb, and SRD Vision; Shareholder Publicly Traded: RxSight; Speaker: OCULUS, Omeros, and Shire; Stock Options: Atia Vision. All other Axiom Ophthalmic staff, planners, reviewers and writers have no financial relationships with ineligible companies. All identified relevant financial relationships have been mitigated and the educational content thoroughly evaluated for fair, balanced, and safe, effective patient care.

OFF-LABEL STATEMENT This educational activity may contain discussion of published and/ or investigational uses of agents that are not indicated by the FDA. The opinions expressed in the educational activity are those of the faculty. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

DISCLAIMER The objective of Axiom Ophthalmic in developing continuing medical education activities is to promote the free expression and interchange of ideas and information for educational purposes. Axiom Ophthalmic does not accept responsibility for any opinions, positions, or statements contained or expressed in such material, and such opinions, positions and statements are not necessarily those of Axiom. Courses are intended to provide instruction leading to new knowledge and/or skills. Axiom Ophthalmic does not certify competence upon completion of the courses. The information presented is not meant to serve as a guideline for patient management. Any procedures, medications or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

OCTOBER 2026

PROGRAM DIRECTOR MARJAN FARID, MD Professor of Ophthalmology Director of Cornea, Cataract and Refractive Surgery Gavin Herbert Eye Institute, UC-Irvine, California mfarid@hs.uci.edu

FACULTY WILLIAM K. CHRISTIAN, MD Medical Director The Vanguard Eye Institute, Santa Monica, California willchristianmd@gmail.com

NIRAJ DESAI, MD Co-Chief Medical Officer Milan Eye Center, Georgia nirajdesaimd@gmail.com

SUMITRA S. KHANDELWAL, MD Professor of Ophthalmology Cornea, Cataract and Refractive Surgery Baylor College of Medicine - Cullen Eye Institute, Houston sumitra.khandelwal@bcm.edu

CAKE

GEORGE O. WARING IV, MD Medical Director and Founder Waring Vision Institute, Mount Pleasant, South Carolina georgewaringiv@gmail.com

OCTOBER 2026

PRECISION PERSONALIZATION: ALIGNING REFRACTIVE IOL TECHNOLOGY WITH PATIENT VISION GOALS Uncorrected presbyopia affects a growing share of the aging cataract population, carrying measurable costs to patient quality of life (QOL) and productivity. However, presbyopia-correcting IOLs (PCIOLs), also known as simultaneous vision IOLs (SVIOLs), remain underutilized relative to eligible candidates. Despite an increasingly sophisticated portfolio spanning enhanced monofocal, extended depth of focus (EDOF), bifocal, trifocal, hybrid/full range of vision, and adjustable technologies, many surgeons lack a standardized framework for matching lens design to individual patient needs. PRESBYOPIA BURDEN Presbyopia is an age-related, progressive loss of accommodative power that typically begins to manifest in the fourth decade of life.1-3 Driven by structural changes in the crystalline lens, ciliary body and zonular apparatus, it is one of the most prevalent ocular conditions worldwide. An estimated 13.6% of American adults aged 50 and older experience near-vision impairment.⁴ In a 2024 Ophthalmic Outlook Group survey, respondents estimated that approximately 51% of 45-year-old patients in their practice had clinically significant presbyopia symptoms.⁵ The consequences of uncorrected presbyopia extend beyond the examination room. Patients report difficulty with fundamental near-vision tasks such as reading, writing, using mobile devices and threading a needle, and they demonstrate measurable QOL deficits. A cross-sectional study found that patients with presbyopia exhibited a 22% decrease in QOL scores compared to peers who were not yet experiencing presbyopia.⁶

The economic toll is equally significant. Uncorrected presbyopia is associated with an estimated $11 billion in lost productivity worldwide each year among adults under age 50.⁷ A UNIQUE OPPORTUNITY Cataract surgery is one of the most common procedures performed in the United States, representing a unique opportunity to address presbyopia simultaneously with cataract removal. 8 The global market for PCIOLs is expanding, and use of these lenses has grown from about 8% to 10% of cataract procedures before the COVID-19 pandemic to about 17% more recently.9 Despite the growth, adoption remains low. On average, respondents to the 2024 Ophthalmic Outlook Group Survey estimated 24% of their cataract procedures involved PCIOLs (Figure 1).⁵ The reasons for this gap are multifactorial. Ophthalmologists cite concerns about visual disturbances such as contrast sensitivity loss and nighttime vision quality, difficulty selecting appropriate candidates, residual refractive error, and uncertainty about how to communicate risks and costs to patients.⁵ Beneath these practical concerns lies a more fundamental challenge: There is no standardized, evidence-based framework for matching a rapidly expanding IOL portfolio to the diverse needs of individual patients. The following consensus statement reflects the perspectives of experienced cataract and refractive surgeons, drawing from current survey data and established clinical literature. Developed to address prevailing gaps in IOL matching strategies, the statement outlines views on patient selection, diagnostics and shared decision-making.

Figure 1. On average, respondents to the 2024 Ophthalmic Outlook Group Survey estimated 24% of their cataract procedures involved PCIOLs.

CAKE

additional visual acuity metrics such as contrast sensitivity and patient-reported outcomes into future versions of the framework. Regarding outcomes, the FVWG agrees that the Assessment of Intraocular Lens Implant Symptoms (AIOLIS) questionnaire is the best tool to use for this purpose. They plan to support initiatives aimed at refining AIOLIS and translating it into multiple languages. The current version has 37 questions covering how often symptoms occur and how bothersome they are, overall vision, near vision, and how often the patient wears glasses or contacts.11

Key takeaway PCIOL adoption remains low relative to eligible candidates, despite growing lens options and expanding market share overall.

EXPERT CONSENSUS GROUP Program Director: Marjan Farid, MD Faculty: William K. Christian, MD; Niraj Desai, MD; Sumitra S. Khandelwal, MD; Julie Schallhorn, MD; George O. Waring IV, MD A FRAMEWORK FOR CATEGORIZING IOL DESIGN Many ophthalmologists approach IOL selection as a primarily optical decision. They choose a lens based on its physical design characteristics without systematically integrating a patient’s visual lifestyle, vocational demands, neuroadaptive capacity and psychological phenotype. Historically, this has been compounded by the absence of a universal classification system for refractive IOLs in clinical practice. The proposed Functional Vision Framework (Figure 2) offers a promising approach, organizing lenses by their functional output rather than by optical mechanism alone.10 A patient-centered lens taxonomy is hypothesized to facilitate more consistent, structured conversations about what a given IOL can realistically deliver for a specific patient.

“As a founding member of FVWG, this has become our primary framework when describing various categories of IOLs,” Dr. George O. Waring IV said. “It transcends the clinic; it has become our framework when working with industry and colleagues as well. If we adopt a standardized approach, it would decrease confusion during our consultations and within the ophthalmology community.” Notably, 83% of the expert consensus group does not currently use the Functional Vision Framework in practice, a sign of how far the field still is from a shared vocabulary for these lenses.12

Notably, 83% of the expert consensus group does not currently use the Functional Vision Framework in practice, a sign of how far the field still is from a shared vocabulary for these lenses.12 Key takeaway A standardized framework, such as the Functional Vision Framework, may reduce confusion during patient consultations and within the ophthalmology community.

THE MODERN REFRACTIVE IOL PORTFOLIO The following is a high-level summary of some of the current advanced technology IOL options available. The framework was created by members of the European Society of Cataract and Refractive Surgeons (ESCRS), American Society of Cataract and Refractive Surgery (ASCRS), Asia-Pacific Association of Cataract and Refractive Surgery (APACRS) and Latin American Society of Cataract and Refractive Surgery (LATAMSCRS), collectively known as the Functional Vision Working Group (FVWG). The group recommends incorporating

Enhanced monofocal IOLs. Sometimes called monofocal-plus IOLs, this design represents the most recent evolution in the monofocal category. Lenses in this group combine a low rate of dysphotopsias with a modestly extended intermediate focal range. They may be suitable for patients who want better intermediate function without accepting the photic phenomena associated with true multifocal or diffractive optics.13

OCTOBER 2026

The TECNIS Eyhance uses a progressive power change and higherorder aspheric surface to add power toward the lens center to improve intermediate vision and maintain a dysphotopsia profile comparable to a conventional monofocal.14 According to an observational study, the enVista Aspire provides useful near and intermediate vision while maintaining excellent distance acuity. The enhanced monofocal offers broader depth of focus with minimal glare, halos and starbursts.15 EDOF IOLs. These lenses generate a continuous, elongated focal region rather than discrete focal points. Their optical mechanisms vary considerably across platforms, including diffractive echelette designs, wavefront-altering technology, aspheric optics and smallaperture (pinhole) approaches. Each carries distinct clinical trade-offs in dysphotopsia risk, near vision performance and pupil dependence.16 The TECNIS Symfony pioneered the EDOF category using an achromatic diffractive echelette design to correct chromatic aberration and extend the range of focus. Clinical evidence showed effectiveness across distances with a lower photic phenomenon profile than traditional multifocals.17 Its current iteration, the TECNIS Symfony OptiBlue, adds a violet light-filtering chromophore to the same optical design.18 The TECNIS PureSee represents the most recent evolution in the EDOF portfolio. It is a refractive, nondiffractive lens with no transition zones or discrete step height changes. The continuous aspheric surface compensates for corneal spherical aberration to extend focal range. Critically, PureSee targets a distinct patient phenotype from the hybrid TECNIS Odyssey IOL, described later: It may be well-suited for patients who prioritize a low visual disturbance profile and high-quality distance and intermediate vision, with functional rather than robust near vision, such as those who are highly light-sensitive, drive frequently at night, and engage in activities requiring high-contrast vision (e.g., pilots, photographers). The PureSee is not intended to replace or compete with the Odyssey; rather, it broadens the lens technologies designed to serve patients who were previously poor candidates for diffractive optics.19 The AcrySof IQ Vivity uses a nondiffractive, wavefront-altering X-Wave technology that stretches and shifts wavefront energy to extend the depth of focus. In clinical trials, 94% of patients reported good or very good unaided distance vision and 92% reported good or very good unaided intermediate vision with a visual disturbance profile similar to a monofocal lens.20 The IC-8 Apthera, based on small-aperture optics to enhance depth of focus, may be particularly suited to patients with irregular corneas or higher-order aberrations.21

Bifocal and trifocal IOLs. Lenses with a multifocal optic split incident light into multiple discrete focal points. Earlier diffractive bifocals, such as the apodized AcrySof ReSTOR and the nonapodized TECNIS Multifocal (no longer available), split light between near and distance foci and carried documented risks of halos, glare and reduced contrast sensitivity.22 Trifocal and full visual range designs were developed in large part to address those limitations. The AcrySof IQ PanOptix, the first FDA-approved trifocal IOL in the United States, creates focal points at 40 cm (near), 60 cm (intermediate) and distance. Pivotal trial data demonstrated 20/20 or better uncorrected distance and intermediate acuity and 20/25 or better uncorrected near acuity. More than 99% of patients undergoing bilateral implantation reported they would choose the same lens again.23 FineVision HP, a hydrophobic trifocal diffractive IOL designed to deliver smooth, continuous range of high-contrast vision across all distances, was approved by the US FDA in 2025. It has been available for use outside the United States for more than 15 years. According to a literature review, the IOL delivers high rates of 20/25 vision at all distances, including near, with consistent range of vision across pupil sizes.24 Hybrid/full range of vision IOLs. The TECNIS Odyssey has a diffractive design with refined ring diameters and step heights to provide continuous range of vision from distance to 33 cm. Compared with TECNIS Synergy, it may provide better contrast in low light and more tolerance for small residual refractive error. A minor refractive miss may be less likely to cost the patient function. 25,26 Odyssey and PureSee serve complementary patients. Odyssey may be well-suited for patients who want the broadest spectacle independence, including near (e.g. avid readers, patients doing fine near work), and PureSee may be well-suited for patients who rely heavily on distance and intermediate vision and are unwilling to accept diffractive-related dysphotopsias. Understanding that distinction helps surgeons build a lens portfolio in which each option has a clear role. Accommodating IOLs. Within this category, the goal is to restore dynamic focus by leveraging ciliary muscle contraction. Single- and dual-optic and curvature-change designs have each been explored, though sustained functional accommodation has proven difficult to achieve, often due to capsular fibrosis over time.27 Adjustable IOLs. The Light Adjustable Lens (LAL) offers the fundamentally different value proposition of fine-tuning refractive power postoperatively using UV light treatment based on the patient’s actual postoperative refraction. 28 The IOL behaves as an enhanced depth of focus once it is adjusted, and full range of vision may be accomplished through monovision strategies based on

CAKE

patient preference. This platform may be particularly valuable for those with a history of refractive surgery, forme fruste keratoconus, and those in whom biometric uncertainty creates refractive risk.

Half (50%) of the expert group believe the EDOF category is the most underutilized platform relative to its clinical value.12

Key takeaway Different IOL platforms are not competitors. They serve distinct, complementary patient phenotypes. A well-built refractive practice offers multiple categories as a differentiated portfolio, not a single best lens.

IOL SELECTION Among the expert consensus group, 83% currently offer five or more categories of IOLs.12 Several factors influence surgeons’ decisions to add new IOL technology to their portfolios. According to the survey, published clinical outcomes/peer-reviewed data and personal experience/feedback from a colleague equally influence their decisions (Figure 3).12 “I talk to my colleagues about their experiences and comfort with new technologies and that, along with my own experience and knowledge, will influence my decisions,” Dr. Marjan Farid said. “For example, I haven’t implanted the FineVision HP IOL yet, but I’m signing up patients because some of my colleagues are having great results.” Half (50%) of the expert group believe the EDOF category is the most underutilized platform relative to its clinical value.12

“It’s genuinely surprising that the conversion rate to EDOF lens implants is as low as it is,” Dr. William K. Christian said. “Those are my happiest postoperative patients by far. The key is to educate patients appropriately during the consultation. I never tell patients they will not need reading glasses. I’ll tell them that they will need reading glasses to read a newspaper or a book, but that they’ll be able to see a computer, iPad or iPhone without reading glasses. That’s an underpromise because most of my patients don’t need to wear reading glasses at all, even to read a book or a newspaper. Underpromising and overdelivering is the golden rule.” Dr. Julie Schallhorn agreed. “EDOF lenses are underutilized, but with the approval of the TECNIS PureSee in the United States, I think that number will climb. I’ve begun to see it at our practice because, in my opinion, the contrast sensitivity profile of that IOL is excellent, and opens the door for many patients who previously may not have benefited from a PCIOL. There’s a huge category of patients with very subtle macular pathology, like epiretinal membranes, who may benefit. In the past, we would not have implanted an advanced technology IOL in those patients.”

Figure 3. Published clinical outcomes/peer-reviewed data (blue) and personal experience/feedback from a colleague (orange) equally influence the expert group’s decision to add a new IOL to their portfolio.

OCTOBER 2026

Dr. Sumitra S. Khandelwal shared similar sentiment and believes there are some excellent technologies that are often underadopted due to clinic flow. “The LAL is underutilized because it’s more of a time commitment to get to the final outcome,” she said. “Patients decline it sometimes because of the extra visits, and surgeons shy away from it for the same reason. At a minimum, it’s three extra visits and, more importantly, you can’t perform the first treatment until the patient has refractive stability. Instead of being done 3 weeks postoperatively, it’s 2 to 3 months. The reality is that postoperative adjustment of refractive error would solve a lot of our issues, we just don’t have an efficient system yet. If someone develops a way to get that down to one treatment or two treatments a few days apart, I think it would be utilized more.” The biggest barriers for the expert group to expand their IOL portfolio were varied and included staff workflow capacity to support advanced technology IOL counseling/testing, consumer confidence index, referring OD knowledge base, general patient awareness and cost to patient.12

Key takeaway Half (50%) of the expert group believe that EDOF lenses are the most underutilized platform relative to their clinical value.

PATIENT PHENOTYPING AND IOL CANDIDATE SELECTION Ophthalmologists vary widely in how they evaluate patient lifestyle needs, personality traits, tolerance for visual phenomena and ocular comorbidities when selecting refractive IOLs. The

variability may contribute to inconsistent lens selection and preventable patient dissatisfaction. Among the expert group, 50% selected ocular health findings (macular status, corneal regularity) as the most important factor when matching a patient to an IOL category (Figure 4).12 “That is the major gateway to all IOL choices: the health of the patient’s eye,” Dr. Schallhorn said. “Somebody who has a pristine cornea, an undamaged macula and is systemically healthy has different IOL choices than somebody who has Parkinson disease, blink apraxia, vitreomacular traction, moderate to severe diabetes or glaucoma.” For eyes with corneal irregularities such as post-LASIK, post-radial keratotomy (RK), or a keratoconus suspect, 80% of the expert group decide on which IOL to recommend on a case-by-case basis depending on topography/tomography findings rather than a fixed threshold.12 “Some corneal irregularities are mild enough that you can still recommend optics that provide a range of vision, for example, an LAL,” Dr. Farid explained. “If their corneal irregularities or their HOAs are very high, like we see in certain post-RK patients, then I may recommend a pinhole optic, like the IC-8 Apthera lens, or I might implant a monofocal lens and put them in a hard contact lens afterward. It’s really based on how much irregularity is on their topography or tomography findings.” In terms of what element of patient phenotyping is most difficult to assess, 60% of the expert group considers personality/psychological profile and expectation tolerance as the most difficult (Figure 5).12 “I’ve been surprised by the laid-back, Type B surfer or retiree who end up quite sensitive to nighttime dysphotopsias or to relying

Figure 4. Among the expert group, 50% selected ocular health findings (macular status, corneal regularity; blue) as the most important factor when matching a patient to an IOL category.

CAKE

patient about range of vision: this lens will give you distance and intermediate, but you’ll have to wear reading glasses. I also think most patients understand halos and glare. But the contrast issues with some lenses that provide a full range of vision are much harder to explain to a patient.” Patient-reported outcome tools, including the previously mentioned AIOLIS questionnaire and the Freedom from Glasses Value Scale (FGVS) as well as wearable visual behavior monitors, may objectively quantify visual priorities before the counseling conversation begins, helping align patient self-perception with surgeon recommendations. 29,30 Figure 5. Sixty percent of the expert group considers personality/psychological profile and expectation tolerance (blue) as the most difficult to assess. on reading glasses for all of their non-electronic reading,” Dr. Christian said. “On the flip side, I’ve had numerous Type A surgeon patients, aeronautical engineers and CPAs who have been shockingly easygoing with their dysphotopsias and paper print reading tolerance. So I think it’s incredibly difficult to attempt to stereotype a patient’s postoperative satisfaction based on their profession or what we might perceive as their personality type.” Dr. Niraj Desai added, “We can educate patients and provide them with questionnaires, but patients can be logical and answer questions in a way that doesn’t reveal their personality or psychological tolerances. It’s probably the most challenging part for surgeons to pinpoint. If you excel at this, you will avoid a lot of misery down the road. I tell patients that their consultation is 10% ophthalmology and 90% psychology.”

I tell patients that their consultation is 10% ophthalmology and 90% psychology. Given how difficult expectation tolerance is to assess, it makes sense that 67% of the expert group chose unrealistic expectations regardless of ocular findings as the scenario that most often accounts for IOL technology mismatches in their revision/ dissatisfaction consults.12 “We’re a practice that provides a substantial number of second opinions from cataract surgery performed elsewhere,” Dr. Khandelwal said. “That’s usually the No. 1 reason why the patient is unhappy. They often have a great range of vision, but they’re unhappy with the dysphotopsia profile or the contrast. It’s important to educate the patient. It’s not hard to inform the

Key takeaways •

•

Ocular health findings (e.g. macular status, corneal regularity) are the gateway for narrowing IOL category, before lifestyle and personality is layered on. Corneal irregularities (e.g. post-LASIK, post-RK, keratoconus suspects) warrant case-by-case evaluation based on topography/tomography rather than a fixed disqualifying threshold. Personality and psychological expectation tolerance are the hardest patient traits to assess, and unrealistic expectations are the leading driver of dissatisfaction and revision consults. Structured patient-reported outcome tools (e.g. AIOLIS, FGVS) can help surface a patient’s true visual priorities before the counseling conversation, reducing reliance on surgeon intuition alone.

OPTIMIZING PREOPERATIVE DIAGNOSTICS AND IOL CALCULATION Refractive misses, residual astigmatism and rotational misalignment persist despite widespread access to modern biometry and digital planning tools, limiting patient achievement of spectacle independence and satisfaction with PCIOLs. On average, surgeons achieve within ±0.50 D of their refractive target approximately 76% of the time, with a range of 70% to 90% across practices.31-33 A major confounding factor is ocular surface disease (OSD). More than 60% of routine cataract patients have asymptomatic dry eye, which can introduce significant measurement noise into keratometry and topography readings if not first optimized.34 Half (50%) of the expert group selected ocular surface optimization prior to biometry as the most critical step for minimizing refractive surprises (Figure 6).12

OCTOBER 2026

and IOL technologies, allowing future adjustments and more contemporary metrics such as lens volume and predictive behavior of eyes susceptible to refractive shifts.” Waring et al published a paper discussing measuring lens thickness (LT), lens diameter (LD) and lens volume (LV) intraoperatively using spectral domain OCT. The retrospective study found that dimensions of the aging lens vary considerably and are most accurately characterized by direct measurement of LT, LD, and LV, rather than making assumptions based on axial length.35

Figure 6. Half of the expert group selected ocular surface optimization prior to biometry (blue) as the most critical step for minimizing refractive surprises. “I try to optimize the ocular surface for every patient prior to their IOL measurements,” Dr. Christian said. “We have a protocol after the consultation where essentially every preoperative patient will begin artificial tears until their IOL measurements. If the patient has even mild OSD, we leave time to treat them prior to their measurement day. For patients with clinically significant dry eyes, we prophylactically place punctal plugs. If they have blepharitis and/or meibomian gland dysfunction, we recommend a regimen of lid scrubs and warm compresses as well. If possible, I recheck them before we schedule them for IOL calculations. After we’ve optimized the ocular surface, I’m completely confident in using a PCIOL.”

IOL power calculation formulas have proliferated in parallel with biometric technology, now spanning multiple primary algorithmic categories: geometric optics, ray tracing, artificial intelligence/machine learning and hybrid approaches. Newer formulas, including AI-based and hybrid approaches (e.g. Kane, Hill-RBF, Ladas Super Formula) have demonstrated superior predictive accuracy in eyes with extreme axial lengths or postrefractive surgery histories, yet adoption in routine practice remains inconsistent.36 Notably, 100% of the expert group rely on the Barrett Universal II IOL power calculation formula the most.12

Key takeaways •

•

Regarding the biggest remaining gap in preoperative diagnostics for refractive cataract surgery, 83% of the expert group selected predicting effective lens positioning accurately (Figure 7).12

Regarding the biggest remaining gap in preoperative diagnostics for refractive cataract surgery, 83% of the expert group selected predicting effective lens positioning accurately (Figure 7).12 “Even with adjustable technology, we do not have a way to predict effective lens position,” Dr. Waring said. “The statistics are startlingly high for short eyes and refractive surprises. It’s a wonderful opportunity for further refinement of our formulas

•

Ocular surface optimization before biometry is considered the single most critical step for minimizing refractive surprises, given how commonly asymptomatic dry eye introduces measurement noise. Predicting effective lens position remains the biggest unresolved gap in preoperative diagnostics. The Barrett Universal II remains the dominant formula in practice, even as newer AI-derived formulas show promise in atypical eyes.

ASTIGMATISM MANAGEMENT PLANNING Approximately half of patients aged 60 years or older have corneal astigmatism exceeding 1.00 D, and up to 22% have astigmatism exceeding 1.50 D.37 Residual astigmatism after cataract surgery is one of the most common causes of patient dissatisfaction with refractive IOLs. Toric platforms are now available across many IOL categories. Despite this, toric IOLs remain underutilized. The 2024 Ophthalmic Outlook Group Survey found that, on average, only 21% of patients with clinically significant astigmatism receive a toric IOL.5 Barriers include uncertainty about when to recommend a toric (with respondents split between 0.75 and 1.00 D thresholds), limited familiarity with posterior corneal

CAKE

Figure 7. Most (83%) of the expert group selected predicting effective lens positioning accurately (blue) as the biggest remaining gap in preoperative diagnostics for refractive cataract surgery. astigmatism measurement and its influence on toric calculation, and residual concerns about rotational stability.⁵ Posterior corneal astigmatism is a particularly underappreciated source of error. The shift from anterior keratometry (K) to total K in IOL calculations has been driven by recognition that posterior corneal power can deviate meaningfully from population-based assumptions, particularly in eyes with prior refractive surgery or corneal disease.38 Among the expert group, 67% said they decide which patients receive a toric version of a PCIOL on a case-by-case basis, based on planned incision and total corneal astigmatism.12 “Astigmatism is underestimated and underappreciated,” Dr. Desai said. “When I’m on peer-to-peer calls around the country, a lot of the refractive misses I hear about come down to residual astigmatism. A surgeon sees 0.30 or 0.40 D of against-the-rule

astigmatism on anterior keratometry and leaves it alone. But once you account for the posterior cornea, the total corneal astigmatism can be 0.75 D or more against the rule, and that’s what shows up in the patient’s refraction. We treat astigmatism aggressively, most often with a toric lens and sometimes with limbal relaxing incisions.” PATIENT COMMUNICATION AND SHARED DECISION-MAKING A cross-sectional study of shared decision-making in IOL selection found that inadequate explanation of treatment advantages and disadvantages was the most common barrier to meaningful patient involvement in the lens selection process.39 Patients who are not clearly informed about the possibility of halos and glare, reduced contrast at night, the neural adaptation process, or the need for occasional reading glasses are significantly more likely to report dissatisfaction regardless of their objective visual outcomes.40 Regarding neural adaptation, Dr. Christian offers his patients an analogy to help them understand the process.

Key takeaways •

•

Toric IOLs remain significantly underused relative to the prevalence of clinically significant astigmatism. Posterior corneal astigmatism adds to anterior against-the-rule astigmatism. Small against-the-rule readings on anterior keratometry can turn into clinically meaningful total corneal astigmatism.

“If I moved you into a second-floor condo in Manhattan, that first year, it might be tough to sleep with all the noise outside that you’re not used to,” he explained. “But if you just ignore it, your brain will innately learn to tune it out, and after a year, you’ll be sleeping well. If instead, every time you hear a horn or an ambulance go by, you turn on your nightlight and write in a journal: ‘3:03 am, heard a garbage truck; 5:15 am, heard someone rev their engine,’ you’re directly inhibiting that natural adaptive process. You have to let it go and not fixate on it.”

OCTOBER 2026

Figure 8. Among the expert group, 67% selected extended consultation time dedicated specifically to expectation setting (blue) as a way to improve informed consent for IOL patients. Among the expert group, 67% selected extended consultation time dedicated specifically to expectation setting as a way to improve informed consent for IOL patients (Figure 8).11 “That’s why I have changed my practice pattern,” Dr. Khandelwal explained. “Previously, I scheduled preoperative consultations on the same day as the cataract evaluations, but I discourage that now. I now do the cataract evaluation in one visit and bring the patient back for the preoperative consultation or, if they live far away, I do a telephone consultation because I think that extra touchpoint helps.” Effective counseling frameworks must address several specific domains: • Realistic probability of spectacle independence by IOL type • The nature, expected frequency and typical neural adaptive timeline for dysphotopsia • The role of bilateral implantation and lens mixing strategies • Out-of-pocket cost, including what is and is not covered by insurance • The informed consent process, particularly for PCIOLs, which should include documentation of patient understanding of trade-offs Studies have shown communicating realistic expectations clearly to patients separates a satisfied one from an unhappy one, regardless of the technical quality of the surgery.41 Structured tools can support the patient education process. Validated patient questionnaires can standardize information gathering prior to

counseling, while patient education videos and shared decisionmaking aids can extend the conversation beyond the examination lane. Practice staff training is equally essential, as surveys have shown many patients receive their first substantive information about IOL options from technicians or counselors rather than directly from the surgeon.⁵

Studies have shown communicating realistic expectations clearly to patients separates a satisfied one from an unhappy one, regardless of the technical quality of the surgery. 41 Despite rigorous counseling frameworks, some patients may still be unhappy with their results. Most (80%) of the expert group agree that the first step when faced with a dissatisfied post-refractive IOL patient is to reassess and optimize the ocular surface/refraction before further intervention.12 “If we know that the patient is dissatisfied, we schedule at the end of the day so that the patient is our only priority,” Dr. Desai said. “Those visits are typically at least 60 minutes, if not longer. The most important step is to simply listen to the patient without

CAKE

interruption to get a sense of what they are saying and the emotion behind it.”

A key conceptual advance is understanding that different IOL platforms are not in competition with one another but rather designed to serve distinct patient profiles and together constitute a comprehensive portfolio for a refractive practice.

Key takeaways •

•

Extended, dedicated consultation time for expectation-setting is viewed as the single highest-impact change practices can make to improve informed consent. When a patient is dissatisfied postoperatively, the first step should be reassessing and optimizing the ocular surface/refraction before considering further intervention.

IMPLEMENTING A COMPREHENSIVE REFRACTIVE IOL PRACTICE The convergence of an aging population, a burgeoning advanced technology IOL portfolio, and rising patient expectations for spectacle independence has made refractive cataract surgery one of the most consequential and demanding domains in modern ophthalmology. Matching the right lens to the right patient is not a static skill. It requires continuous updating as new platforms enter clinical practice with distinct optical profiles and candidate populations. The pace of IOL innovation has outstripped the capacity of many busy clinical practices to systematically evaluate new designs. Ophthalmologists may conflate lenses within broad categories (e.g. treating all EDOF lenses as clinically equivalent) or be unfamiliar with how optical trade-offs manifest differently across patient populations. The result is either overly conservative prescribing and defaulting to monofocal IOLs for all but the most straightforward candidates or inappropriate lens selection, such as implanting a trifocal IOL in a patient with macular pathology or high photic phenomenon sensitivity. A key conceptual advance is understanding that different IOL platforms are not in competition with one another but rather designed to serve distinct patient profiles and together constitute a comprehensive portfolio for a refractive practice. A wellconstructed refractive practice offers all of them as components of a differentiated, complementary portfolio in which each IOL expands access to advanced technology IOLs rather than displacing another.

erosions) three years prior that resolved completely only after phototherapeutic keratectomy. On exam, VA was 20/30 OD but 20/125 OS (pinhole 20/50) with manifest refraction showing significant hyperopic astigmatism OS (+2.75 +0.75 x 145) versus a nearly plano OD, plus 1+ NS OU, 2+ posterior subcapsular cataract OS, and a history of extensive panretinal photocoagulation OU without macular edema. Corneal imaging and aberrometry were used to characterize the irregular OS cornea before IOL selection (Figure 9). A LAL and an IC-8 Apthera small-aperture (pinhole) IOL were considered. LAL typically suits eyes with low HOAs but will have a longer postoperative period for stabilization and finalization of adjustments whereas a small aperture or monofocal-plus-rigidcontact-lens approach suits eyes with high HOAs. Given the degree of corneal irregularity, a monofocal IOL was placed OD and the small-aperture IOL was implanted OS. Postoperatively, the patient was 20/HAPPY, achieving 20/20 UCVA OD and 20/30 J2 OS. This case illustrates a practical framework for lens selection in eyes with significant corneal irregularity secondary to prior OSD. Case 2: LAL in stable keratoconus | Niraj Desai, MD A 70-year-old man with four decades of bilateral keratoconus, stable by history and serial refraction, with no prior CXL or corneal surgery, presented with progressive glare, halos and blur from visually significant nuclear and cortical cataracts. Brightness acuity testing reduced his vision to 20/200 in both eyes despite otherwise clear corneas.

Case 1: A patient with an irregular cornea | Marjan Farid, MD A 56-year-old woman with diabetes presented with poor vision OU and imbalance. She had a history of severe left eye recurrent corneal erosion (limbus-to-limbus epithelial sheet

He habitually relied on scleral lenses and progressive spectacles but hoped to escape scleral lens dependence, so he declined a monofocal option and chose bilateral LALs after counseling on the trade-off (i.e. the ability to refine the result after healing with the

OCTOBER 2026

Figure 9. Corneal imaging and aberrometry were used to characterize the irregular OS cornea before IOL selection.

CAKE

Right eye

Left eye

Figure 10. Tomography confirmed inferior corneal steepening without scarring or hydrops.

understanding that once the lens is set to his corneal astigmatism, going back to a scleral lens would no longer be a simple fallback). Tomography confirmed inferior corneal steepening without scarring or hydrops (Figure 10), more advanced on the left (Kmax 54.60 D, ABCD A2B4C1) than the right (Kmax 51.00 D, A1B2C0). Biometry showed long axial lengths and markedly asymmetric keratometric astigmatism (4.14 D OS vs 0.83 D OD). In keratoconus, keratometric and refractive astigmatism often do not match because keratometry samples only a small central zone of an irregular cornea. Here, the left eye refracted 2.50 D of cylinder after surgery but before any light adjustment. Long eyes and an unreliable read on the cornea are exactly the conditions that undermine standard IOL power prediction, and that was the core rationale for an adjustable platform.

Macular OCT was obtained preoperatively to rule out a competing cause of visual limitation and was normal in both eyes. Uncomplicated phacoemulsification was performed sequentially (OD then OS 1 week later, with light treatment deliberately deferred to 5 weeks given the keratoconus to allow full refractive settling). Each eye then underwent light adjustment, with a second adjustment in the left eye only, followed by two lock-in treatments (Figure 11). In the left eye, refractive astigmatism fell from 2.50 to 0.50 D, uncorrected distance acuity reached 20/25-2 and bestcorrected acuity improved to 20/20. Final uncorrected distance acuity was 20/25+2 OD and 20/25-2 OS. The left eye, which had the more advanced cone and had never been better than 20/30 preoperatively even in a scleral lens, became the better-seeing eye with correction. Both eyes read J1+ uncorrected at near despite

Figure 11. Each eye then underwent light adjustment, with a second adjustment in the left eye only, followed by two lock-in treatments.

OCTOBER 2026

Figure 12. Preoperative cataract exam demonstrated a normal anterior segment, 3+ NS cataract and a fundus (A) with superior laser scars and a mild epiretinal membrane on OCT (B).

CAKE

a distance target, most likely reflecting the added depth of focus that the cone’s HOAs can provide. Binocular uncorrected distance acuity was 20/25, and the patient was weaned off scleral lenses entirely, describing it as the best vision he can remember. In this patient, long-term clinical stability was the key entry criterion. The appropriate comparison is the patient’s own historical best rather than emmetropia. Candidates who might still need rigid lens correction in the future are typically a poor fit for this approach. This is a single case with roughly three months of follow-up, so long-term refractive and corneal stability with the LAL in keratoconus remains unestablished.

Case 3: A patient with history of macula-on retinal detachment | Julie Schallhorn, MD A 65-year-old woman with a history of macula-on retinal detachment 6 months prior presented with worsening nuclear sclerosis. Preoperative cataract exam demonstrated a normal anterior segment, 3+ NS cataract, and a fundus with superior laser scars and a mild epiretinal membrane on OCT (Figure 12). After discussion of lens options, she opted for a TECNIS PureSee lens. At postoperative month 1, she was 20/25 at distance, J4 at near uncorrected with a manifest refraction of -0.25 +0.50 x 047 and a best corrected acuity of 20/20.

CONCLUSION As the PCIOL portfolio continues to expand in scope and complexity, closing the gap between technology availability and patient access demands a structural shift toward a standardized framework. The ideas reflected here underscore that successful IOL matching is rarely a single decision made at the point of surgery but rather a continuous process spanning ocular surface preparation, biometric precision, astigmatism planning and extended patient communication. Ultimately, this stands to benefit not only surgical outcomes but the growing population of patients seeking full visual independence after cataract surgery.

This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.

OCTOBER 2026

REFERENCES 1.

O’Keefe M, O’Keeffe N. Corneal surgical approach in the treatment of presbyopia. J Clin Exp Ophthalmol. 2016;7(1).

September 14, 2026. Available at: https://www. reviewofophthalmology.com/article/dawn-of-themonofocal-plus-era

Paley GL, Chuck RS, Tsai LM. Corneal-based surgical presbyopic therapies and their application in pseudophakic patients. J Ophthalmol. 2016;2016:5263870.

Torricelli AA, Junior JB, Santhiago MR, Bechara SJ. Surgical management of presbyopia. Clin Ophthalmol. 2012;6:1459-1466.

14. Auffarth GU, Gerl M, Tsai L, et al; Quantum Study Group. Clinical evaluation of a new monofocal intraocular lens with enhanced intermediate function in cataract patients. J Cataract Refract Surg. 2021;47(2):184-191.

Zebardast N, Friedman DS, Vitale S. The prevalence and demographic associations of presenting nearvision impairment among adults living in the United States. Am J Ophthalmol. 2017;174(1):134-144.

The 2024 Ophthalmic Outlook Survey Overview. The Fundingsland Group; 2024.

Muhammad N, Alhassan M, Umar M. Visual function and vision-related quality of life in presbyopic adult population of Northwestern Nigeria. Niger Med J. 2015;56(5):317.

Frick KD, Joy SM, Wilson DA, Naidoo KS, Holden BA. The global burden of potential productivity loss from uncorrected presbyopia. Ophthalmology. 2015;122(8):1706–1710.

Davis G. The Evolution of Cataract Surgery. Mo Med. 2016;113(1):58-62.

The 2022 ASCRS Clinical Survey. American Society of Cataract and Refractive Surgery; 2022. Accessed September 30, 2026.

10. Fernández J, Koch DD, Barrett GD, Andrade N Jr, Ribeiro F; Functional Vision Working Group. Global consensus on the evidence-based functional classification of simultaneous vision IOLs. J Cataract Refract Surg. 2026;52(3):219-222. 11. FDA.gov. MDDT Summary of Evidence and Basis of Qualification Decision for AIOLIS. Accessed September 14, 2026. Available at: https://www.fda. gov/media/178644/download 12. 2026 Precision Personalization: Aligning Refractive IOL Technology With Patient Vision Goals Survey. Axiom Ophthalmic; 2026. 13. Leonard C. Dawn of the Monofocal “Plus” Era. Review of Ophthalmology. May 6, 2020. Accessed

15. Feltrin de Barros M, Gouvea L, Hill C, Santhiago MR, Waring GO 4th, Rocha KM. Optical performance and refractive outcomes of a new monofocal intraocular lens with intermediate optimized optics. J Refract Surg. 2025;41(10):e1069-e1075. 16. Kohnen T, Berdahl JP, Hong X, Bala C. The novel optical design and clinical classification of a wavefront-shaping presbyopia-correcting intraocular lens. Clin Ophthalmol. 2023;17:2449-2457. 17. Cochener B, Concerto Study Group. Clinical outcomes of a new extended range of vision intraocular lens: International Multicenter Concerto Study. J Cataract Refract Surg. 2016;42(9): 1268–1275. 18. Chang DH, Kao AA, Huggins LK, Albert JN, Whinery JN, Camirand BM. Clinical evaluation of violet light filtration and high-resolution lathing on a diffractive extended depth of focus IOL. Ophthalmol Ther. 2024;13(12):3135-3147. 19. Ophthalmology Times. TECNIS PureSee IOL launches in US following FDA approval for cataract surgery. June 11, 2026. Accessed September 14, 2026. Available at: https://www. ophthalmologytimes.com/view/tecnis-pureseeiol-launches-in-us-following-fda-approval-forcataract-surgery 20. Eyewire. Alcon Commercially Launches AcrySof IQ Vivity Extended Depth of Focus IOL in US. January 7, 2021. Accessed September 14, 2026. Available at: https://eyewire.news/articles/alcon-launchesacrysof-iq-vivity-extended-depth-of-focus-iol-inus/?c4src=article%3Ainfinite-scroll 21. Grabner G, Ang RE, Vilupuru S. The small-aperture IC-8 intraocular lens: a new concept for added depth of focus in cataract patients. Am J Ophthalmol. 2015;160(6):1176-1184.

CAKE

22. de Silva SR, Evans JR, Kirthi V, Ziaei M, Leyland M. Multifocal versus monofocal intraocular lenses after cataract extraction. Cochrane Database Syst Rev. 2016;12:CD003169. 23. Sudhir RR, Dey A, Bhattacharrya S, Bahulayan A. AcrySof IQ PanOptix intraocular lens versus extended depth of focus intraocular lens and trifocal intraocular lens: a clinical overview. Asia Pac J Ophthalmol (Phila). 2019;8(4):335-349. 24. Ristvedt D, Bosc C, Thompson V. Clinical outcomes of a hydrophobic trifocal diffractive intraocular lens: a literature review. Front Med (Lausanne). 2025;12:153316. 25. Bissen-Miyajima H, Midorikawa M, Fujisaki R, Ota Y, Minami K, Honda R. Early clinical results of a newly developed continuous range of vision intraocular lens. Ophthalmol Ther. 2025;14(11):2937-2945. 26. Modi S. A Decade of PanOptix: How Does Tecnis Synergy Stack Up? Cataract & Refractive Surgery Today. 2024. Accessed September 14, 2026. Available at: https://crstoday.com/articles/a-decadeof-panoptix-how-does-tecnis-synergy-stack-up/ a-decade-of-panoptix-how-does-tecnis-synergystack-up/ 27. Pepose JS, Burke J, Qazi M. Accommodating intraocular lenses. Asia Pac J Ophthalmol (Phila). 2017;6(4):350-357. 28. Thompson V. New Light Adjustable Lens Leading the Evolution of Cataract Surgery. Cataract and Refractive Surgery Today. July 2014. Accessed September 14, 2026. Available at: https://crstoday. com/topics/general/new-light-adjustable-lensleading-the-evolution-of-cataract-surgery/42683/ 29. Levy P, Elies D, Dithmer O, et al. Development of a new subjective questionnaire: The Freedom from Glasses Value Scale (FGVS). J Refract Surg. 2010;26(6):438-446. 30. Cummings A. New refractive technologies: early experiences, thoughts: Monitoring visual behavior. Ophthalmology Times. September 24, 2018. Accessed September 14, 2026. Available at: https://www.ophthalmologytimes.com/view/newrefractive-technologies-early-experiences-thoughts 31. Melles RB, Holladay JT, Chang WJ. Accuracy of intraocular lens calculation formulas. Ophthalmology. 2018;125:169-178.

32. Hipólito-Fernandes D, Elisa Luís M, Gil P, Maduro V, Feijão J, Yeo TK, Voytsekhivskyy O, Alves N. VRF-G, a New Intraocular Lens Power Calculation Formula: A 13-Formulas Comparison Study. Clin Ophthalmol. 2020;14:4395-4402. 33. Savini G, Hoffer KJ, Balducci N, Barboni P, SchianoLomoriello D. Comparison of formula accuracy for intraocular lens power calculation based on measurements by a swept-source optical coherence tomography optical biometer. J Cataract Refract Surg. 2020;46:27-33. 34. Trattler WB, et al. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423. 35. Waring GO 4th, Chang DH, Rocha KM, Gouvea L, Penatti R. Correlation of Intraoperative Optical Coherence Tomography of Crystalline Lens Diameter, Thickness, and Volume with Biometry and Age. Am J Ophthalmol. 2021;225:147-156. 36. Stopyra W, Langenbucher A, Grzybowski A. Intraocular lens power calculation formulas— a systematic review. Ophthalmol Ther. 2023;12:2881-2902. 37. Leon P, Pastore MR, Zanei A, et al. Correction of low corneal astigmatism in cataract surgery. Int J Ophthalmol. 2015;8(4):719-724. 38. Wendelstein JA, Hoffmann PC, Hoffer KJ, et al. Differences Between Keratometry and Total Keratometry Measurements in a Large Dataset Obtained With a Modern Swept Source Optical Coherence Tomography Biometer. Am J Ophthalmol. 2024;260:102-114. 39. Dai J, Hua Y, Chen Y, et al. Current status of shared decision-making in intraocular lens selection for cataract surgery: A cross-sectional study. Patient Prefer Adherence. 2024;18:1311-1321. 40. Gibbons A, Ali TK, Waren DP, Donaldson KE. Causes and correction of dissatisfaction after implantation of presbyopia-correcting intraocular lenses. Clin Ophthalmol. 2016;10:1965-1970. 41. Kohnen T. IME Video Interview: Matching patient needs with latest presbyopia lens technologies. ESCRS. 2024. Accessed September 30, 2026. Available at: https://www.escrs.org/channels/ forum/ime-video-interview-matching-patient-needswith-latest-presbyopia-lens-technologies/

OCTOBER 2026