Several steps needed for presbyopia-correcting IOLs after corneal refractive surgery
Key takeaways:
- After corneal refractive surgery, patients need careful evaluation when receiving a presbyopia-correcting IOL.
- Light Adjustable Lens and Apthera may be the best choices and can lead to positive outcomes.
KOLOA, Hawaii — With appropriate IOL selection, careful preoperative assessment and accurate calculations, presbyopia-correcting IOLs can be successful in patients who previously underwent corneal refractive surgery, according to a speaker.
At Hawaiian Eye 2025, Zaina Al-Mohtaseb, MD, said that the first priority is to understand what the patient’s prior treatment was in order to choose the best IOL calculation formula. The next step is to determine the corneal aberration profile, the degree of corneal irregularity and, most importantly, candidacy for a refractive touch-up if needed “because we are not as good in terms of refractively hitting the target,” she said.
Topographic maps should be carefully examined before deciding what lens can be implanted. Presence of irregularities, Salzmann’s nodules, epithelial basement membrane dystrophy and ocular surface disease must be assessed.
“When looking at the topography, you want to make sure it’s regular, especially if you’re going to use astigmatism-correction lenses,” Al-Mohtaseb said. “Look at decentered ablations because all of these things can result in significant higher-order aberrations.”
All measurements — refraction, topography and biometry — should be taken before putting any drops in the eye, she recommended. A macula OCT will also help rule out the presence of epiretinal membranes or other subtle pathologies.
Post-refractive patients have high expectations, often unrealistic, and it is therefore important to be generous with chair time and choose an IOL that has more predictable outcomes. Al-Mohtaseb said she would not implant a diffractive lens in these patients, and her primary choices are the Apthera (Bausch + Lomb) and the Light Adjustable Lens (LAL, RxSight), with a form of mini-monovision.
“I don’t tell my patients they are going to see distance, intermediate and reading perfectly without any compromise. I tell them I can get them excellent distance and intermediate, but they might need some reading glasses,” she said.
With the LAL, she reported achieving 20/25 or better at distance in 97% of myopic LASIK and PRK patients, in 82% of hyperopic patients and in as many as 83% of post-RK patients.
“I was shocked at the outcomes with our RK patients, and those are the patients that have regular astigmatism with their RK,” she said.
At near, results were also good, with the majority of patients achieving J3 or better.
In eyes with irregular corneas, she prefers to use the Apthera. At distance, 75% of her patients are 20/30 or better, and at near, 77% are 20/40 or better with this lens, she said.
“A lot of these patients end up not being contact lens dependent. So, that’s what I do for my post-refractive patients,” she said.
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Al-Mohtaseb Z. Presbyopia correcting implants in patients with previous corneal refractive surgery: They want them ... considerations to optimize success. Presented at: Hawaiian Eye 2025; Jan. 18-24, 2025; Koloa, Hawaii.
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