Meeting expectations with evolving technology

As an ophthalmology resident, I am increasingly meeting patients who underwent LASIK surgery 15 or 20 years ago. They were the early adopters of refractive surgery, thrilled to toss their glasses in their youth. Now in their 50s or 60s, these same patients are grappling with presbyopia often compounded by the beginnings of cataracts. From their perspective, it feels like a cruel joke: “Doc, my LASIK was supposed to fix my vision forever, and now I need reading glasses?” They arrive seeking a solution with the same confidence that technology will come to the rescue.

Modern ophthalmology has some exciting tools to offer. However, as I have learned, helping patients with a history of LASIK regain spectacle independence is equal parts exciting and challenging. It requires blending cutting-edge techniques with a healthy dose of honest counseling and tempered expectations.

Challenges in managing presbyopia after LASIK

The corneas of patients who underwent LASIK have been surgical reshaped, which means the standard cataract surgery measurements and formulas become less predictable. Even in the best hands, achieving the refractive outcome after cataract surgery is more difficult in eyes that underwent previous laser vision correction.¹ Studies have shown that fewer post-LASIK eyes end up within that coveted plus or minus 0.50 D of the intended target compared with eyes with no previous surgery, leaving a sizable minority of patients with residual prescription that might blur their vision at some distances.² That risk of refractive surprise looms large in my mind every time I see that telltale flat cornea on topography from a prior myopic LASIK procedure. These patients once enjoyed a perfect outcome, and they expect nothing less the second time around. It is humbling to explain that this time the task is more complicated.

Why is it tricky? The standard biometry devices and formulas were developed for untreated eyes. LASIK fundamentally alters corneal curvature and optics, and these tools may have difficulty accurately predicting the effective lens position and ideal IOL power in these altered eyes.^3,4 Early in my training, I learned to gather every piece of data available: multiple keratometry readings, corneal topography maps, knowledge of the original LASIK correction if possible, and even the patient’s historical refraction.

There is no shortage of IOL power calculation formulas—ranging from classic options such as the Haigis-L and the Barrett True-K to more recent artificial intelligence (AI)–based calculators. However, each method has its limitations. I routinely double- and triple-check IOL power selections using multiple approaches to optimize accuracy. It is a blend of science and art. I counsel patients that having a plan B, such as a laser enhancement or even an IOL exchange, may be necessary if the desired refractive outcome is not achieved.

Light adjustable lenses: Fine-tuning after surgery

One of the most intriguing innovations for managing refractive uncertainty in this population is the Light Adjustable Lens (LAL; RxSight, Inc). This lens allows postoperative modification of its refractive power using targeted UV light treatments. For patients with prior LASIK, the LAL provides a safeguard against refractive surprises. Rather than relying solely on preoperative calculations, the LAL is implanted during cataract surgery, and the refractive outcome is fine-tuned several weeks later in vivo. After adequate healing, the patient undergoes refraction, followed by adjustment sessions using a specialized UV-light delivery device to modify and then lock in the lens power. Multiple treatments can be performed if necessary, allowing adjustments in sphere and even modest levels of astigmatism to optimize the visual outcome.⁵

Based on my clinical observations of attendings incorporating the LAL into practice, its use has increased confidence in managing complex eyes. One memorable patient had undergone LASIK twice—an initial treatment followed by a touch-up years later—and was understandably anxious about cataract surgery due to long-standing satisfaction with her vision. She elected to receive the LAL, and after a few adjustment sessions, her vision was optimized for both distance and intermediate ranges. The outcome was highly satisfactory for the patient and provided reassurance to the clinical team. This approach appears to expand the typical limitations of cataract formulas. Emerging studies support these observations, demonstrating that a majority of patients with previous refractive surgery implanted with the LAL achieve refractive outcomes within 0.5 D of the target and experience excellent vision.⁶ ⁶

The LAL requires a significant commitment to multiple follow-up visits for lens power adjustments. During this period, patients must consistently wear special UV-blocking glasses to prevent unintended UV exposure that could alter the lens power. This process adds several weeks to the visual journey. Not all patients are eager to commit to the extra visits or to wear UV-blocking glasses for more than a month.

Although the LAL enables correction of spherical and cylindrical errors, it cannot completely eliminate higher-order aberrations or issues such as irregular corneas from prior refractive surgeries. I still examine corneal topography closely, and if significant irregularities or scarring are present, even a perfectly tuned refraction may not result in crisp vision. In essence, the LAL provides added control and peace of mind in many post-LASIK cases but is used with caution. Patient selection remains key, and counseling about trade-offs and realistic goals is critical. When the fit is right, delivering that final “wow” moment after adjustments is incredibly satisfying.

EDOF IOLs: Balancing clarity and range

Extended depth-of-focus (EDOF) IOLs are another option for managing presbyopia in patients with previous LASIK. These lenses—like the Tecnis Symfony (Johnson & Johnson Vision), Vivity (Alcon), and others—aim to provide a continuous range of vision (especially distance and intermediate, with some functional near) while causing fewer halos and glare than traditional multifocal lenses.⁷

In a way, an EDOF lens is a middle ground between a monofocal and a multifocal IOL that mitigates some of their shortcomings. For a patient with a history of LASIK, preserving quality of vision is paramount. These patients were accustomed to crisp, aberration-free distance vision from their LASIK and are unlikely to tolerate a significant drop in contrast sensitivity. An EDOF lens tends to be more forgiving of minor refractive errors or slight misalignment. If a calculation is off by 0.25 to 0.50 D (which is not uncommon in these post-LASIK cases), an EDOF lens can often still deliver very good vision at multiple distances because of its extended focus range. Similarly, if the lens is not perfectly centered on the optical axis or the patient’s pupil dynamics are not ideal, an EDOF lens handles it better than many multifocal designs that split light into discrete focal points.

At the Duke Eye Center, the EDOF IOL has largely supplanted the multifocal trifocal when treating patients with previous refractive surgery who desire presbyopia correction. As a resident, I was initially skeptical. I had read the literature recommending against multifocal IOLs in eyes with prior LASIK due to concerns about glare and unpredictable outcomes.³ The idea of adding diffractive rings to an already aberrated optical system made me nervous. My attendings echoed this caution: If the patient had a high myopic LASIK treatment, the adverse effects of a multifocal lens could be magnified. Instead, options like mini-monovision or newer platforms such as the Vivity EDOF lens would be discussed. Over time I’ve gained confidence that an EDOF lens can provide a nice balance for these patients, offering a meaningful amount of near vision for daily tasks (like reading a menu or using a smartphone) with minimal sacrifice to distance clarity. However, I always explain the drawbacks; patients will likely still need reading glasses for small print or prolonged reading, and they might notice mild halos around lights at night, although usually less intense than what some patients with multifocal lens report.

As with the LAL, the key to success with an EDOF lens is meticulous patient selection and counseling. If someone is extremely sensitive about night driving or demands razor-sharp vision at all distances, even an EDOF lens might disappoint them. Many patients with prior LASIK are open to these discussions. They remember researching the pros and cons of LASIK and often approach this next chapter with similar pragmatism. When used thoughtfully, an EDOF lenscan play a big role in the refractive strategy for patients with previous LASIK.

Monofocal plus IOLs: Tailoring optics to LASIK-induced asphericity

At institutions like Cleveland Eye Clinic, monofocal plus IOLs have become a cornerstone for managing presbyopia in patients with prior LASIK, offering a strategic compromise between visual quality and functional range. These lenses—such as the Tecnis Eyhance (Johnson & Johnson Vision); Aspire (Bausch + Lomb Corporation), and RayOne EMV (Rayner)—can be strategically matched to the corneal asphericity induced by prior LASIK. Eyes with post–myopic LASIK tend to have positive spherical aberration due to a flatter central cornea, whereas post–hyperopic LASIK eyes often carry negative spherical aberration from a steepened central shape. This aberration can sometimes provide a small degree of natural depth of focus—but at the cost of reduced contrast and degraded image quality.

Depending on how satisfied the patient was with the original LASIK outcome, surgeons may choose to preserve the cornea’s native asphericity or normalize it with an appropriately matched IOL. For example, if a patient with post–myopic LASIK is experiencing poor image quality or reduced contrast sensitivity, a lens with negative spherical aberration—such as the Tecnis Eyhance or Aspire—may be selected to offset the cornea’s positive spherical aberration and restore a more balanced optical profile. Conversely, in post–hyperopic LASIK eyes that typically have negative corneal spherical aberration, surgeons might choose a positive aspheric lens like the RayOne EMV to rebalance the optics. If the patient is generally happy with the LASIK result and maintaining that balance is a priority, a neutral aspheric lens such as the enVista (Bausch + Lomb Corporation) may be chosen, as it offers excellent image quality without further altering spherical aberration.

In practice, these lenses are often paired with mild monovision (eg, plano in the dominant eye, –0.50 D in the nondominant eye) to extend near vision functionality. Although these lenses will not deliver complete spectacle independence, they offer a reliable and well-tolerated solution that aligns with the nuanced needs of eyes with prior LASIK. By thoughtfully addressing asphericity and using monofocal plus IOLs to either complement or correct it, care can be individualized and outcomes optimized in this complex but rewarding patient group. Many of these patients were first introduced to the concept of monovision at the time of their original LASIK—some embraced it, others declined. Cataract surgery provides a natural opportunity to revisit that earlier choice, reestablish the preferred visual balance, or change course entirely based on how visual needs and preferences have evolved over time.

AI and advanced biometry: Precision in planning

One of the most impactful revolutions in cataract surgery is the rise of AI-driven biometry and IOL power calculation tools. As a technology and innovation nerd, I find this development exciting. The premise is simple: Feed computers a ton of data from previous surgeries, and let them discern patterns and improve predictions for the next surgery. In practice, this has led to new calculation formulas and software platforms that are especially useful for those hard-to-predict eyes—including eyes with prior LASIK.

In clinic, the latest generation of formulas is used when planning surgery for patients with previous LASIK. Classics like Barrett True-K, specifically designed for patients post keratorefractive surgery, are standard. Additional options include the American Society of Cataract and Refractive Surgery online calculator suite and proprietary algorithms that incorporate machine learning. Some methods, such as the Hill-RBF Calculator or the Kane Formula, use AI trained on large data sets of surgical outcomes to predict IOL power.^8,9 Certain companies are even integrating AI directly into new optical biometers. The goal is to reduce refractive surprises by learning from thousands of previous patients. Based on collective experience, the chances of hitting target outcomes continue to improve.

Does it make a difference for eyes with prior LASIK? It likely does, albeit incrementally. A senior surgeon once advised: “In these eyes, check everything twice and don’t trust any single formula.” When the Barrett True-K, a newer AI formula, and perhaps a ray-tracing calculation all converge on the same IOL power, it offers reassurance that the chosen path is sound. The strength of AI-driven approaches lies in their ability to continuously improve. As more patients with prior LASIK undergo cataract surgery and those results are fed back into the algorithms, prediction accuracy is expected to increase. Published studies and meta-analyses already suggest that some AI-enhanced formulas can outperform traditional ones in atypical eyes—such as eyes with very short or very long axial lengths or post-refractive surgery. This serves as a strong example of technology augmenting surgical judgment—not replacing it, but curating data to support the best possible decisions for each patient.

That said, I remain cautious. These tools are only as reliable as the data used to train them, and outliers still exist. An eye with prior LASIK can present unique quirks that no formula fully accounts for, such as irregular astigmatism or subtle lens tilt. Advanced biometry does not replace sound clinical reasoning or eliminate the importance of discussing uncertainties. If anything, the availability of sophisticated calculations highlights the need for transparent patient counseling. Patients are told, “We have very sophisticated calculators and even AI helping us choose the implant power, and this dramatically improves our odds. Think of it like using GPS to plan your route. It gets us much closer to where we want to be. But because your eye has been operated on before, the road is a little less familiar, so we might need to take a detour and fine-tune afterward.” Most patients appreciate that level of honesty and the presence of contingency plans. Ultimately, even the most advanced formula is no substitute for setting appropriate expectations.

Shifting strategies

With these new technologies—LAL, monofocal plus, EDOF IOLs, advanced formulas—my approach for patients with presbyopia after LASIK surgery has evolved into a more confident and proactive one. Early on, I admittedly felt a bit of dread when a patient with prior LASIK presented for a cataract evaluation. The combination of high patient expectations and the inherent limitations in achieving perfect outcomes was intimidating. Now, armed with a growing toolbox, I see these cases more as a collaborative project with the patient. The conversation focuses on what can be achieved and the strategies available to meet their goals. Surgical decisions are no longer one-size-fits-all; they are highly individualized.

When it comes to patient counseling, these technologies have arguably made the conversations both easier and more complex. Easier, in the sense that I can now tell patients, “We have more ways than ever to get you the vision you want.” And I can offer concrete options: “We could use this adjustable lens to fine-tune your outcome or this newer lens design that gives you a range of vision, and we have smart calculators to guide us.” The more challenging aspect is explaining the nuances of each option and managing expectations. Analogies are often helpful in these conversations. The LAL adjustment process, for example, is described as similar to a camera with autofocus—it gets close but then allows for manual fine-tuning before taking the final shot. Patients are told, “That’s what we’re doing with your vision after surgery: dialing it in so it’s picture perfect.”

Looking ahead

Managing presbyopia in patients with prior LASIK surgery entails a combination of high-tech innovation and the timeless art of doctor-patient communication. As a resident, I feel fortunate to train in an era in which there are answers for the LASIK generation now facing new vision needs. The landscape is different from a decade ago. Tools like the LAL offer a way to outsmart refractive surprises; monofocal plus IOLs assist in restoring optics and asphericity; EDOF IOLs provide functional vision with fewer compromises; and AI-powered planning tools continue to reduce the margin of error. These advances have tangibly improved outcomes and patient satisfaction in my experience so far, and they have made this growing patient population less intimidating to serve.

Yet, experience has also taught me to stay grounded. Even the most modern technology does not replace the fundamentals of careful examination, individualized planning, surgical finesse, and empathetic counseling. Even the most experienced surgeons are still adapting, learning, and fine-tuning their approach. When asked how many cases it took to become an authority in cataract surgery, my coauthor William F. Wiley, MD, once told me, “I’ll let you know when I get there. It’s not about chasing every new device, but rather about knowing when and how to use the right tool for the right patient.” That means staying curious about innovation, but thoughtful and measured in application.

There’s something uniquely gratifying about helping someone who once experienced visual freedom regain it later in life. These patients understand what good vision feels like, and when the outcome is right, their appreciation is unmistakable. Being part of that second chapter in their visual journey is a privilege. As technology continues to evolve—from more adaptable lenses to smarter surgical planning systems—ophthalmologists are better equipped than ever to deliver consistent, high-quality outcomes. The challenge lies not only in keeping up with innovation but in knowing how to use it wisely. Technology does not make decisions; it raises the bar. That, more than anything, is what makes refractive surgery both demanding and deeply fulfilling.

References

1. Chean CS, Aw Yong BK, Comely S, et al. Refractive outcomes following cataract surgery in patients who have had myopic laser vision correction. BMJ Open Ophthalmol. 2019;4(1):e000242. doi:10.1136/bmjophth-2018-000242

2. Chow SSW, Chan TCY, Ng ALK, Kwok AKH. Outcomes of presbyopia-correcting intraocular lenses after laser in situ keratomileusis. Int Ophthalmol. 2019;39(5):1199-1204. doi:10.1007/s10792-018-0908-0

3. Ferguson TJ, Randleman JB. Cataract surgery following refractive surgery: principles to achieve optical success and patient satisfaction. Surv Ophthalmol. 2024;69(1):140-159. doi:10.1016/j.survophthal.2023.08.002

4. Anders P, Anders LM, Barbara A, Szentmary N, Langenbucher A, Gatzioufas Z. Intraocular lens power calculation in eyes with previous corneal refractive surgery. Ther Adv Ophthalmol. 2022;14:25158414221118524. doi:10.1177/25158414221118524

5. Jun JH, Lieu A, Afshari NA. Light adjustable intraocular lenses in cataract surgery: considerations. Curr Opin Ophthalmol. 2024;35(1):44-49. doi:10.1097/ICU.0000000000001015

6. Jones M, Terveen DC, Berdahl JP, Thompson V, Kramer BA, Ferguson TJ. Clinical outcomes of the light-adjustable lens in eyes with a history of prior corneal refractive surgery. J Cataract Refract Surg. 2024;50(9):936-941. doi:10.1097/j.jcrs.0000000000001481

7. Garg SS. Preoperative considerations with extended depth-of-focus lenses. Ophthalmology Times. 2017;42:18-19.

8. Gouvea L, Sioufi K, Brown CE, Waring Iv G, Chamon W, Rocha KM. Refractive accuracy of Barrett True-K vs intraoperative aberrometry for IOL power calculation in post-corneal refractive surgery eyes. Clin Ophthalmol. 2021;15:4305-4315. doi:10.2147/OPTH.S334489

9. Hill WE, Wang L, Koch DD. Improving IOL power calculations using artificial intelligence. Ophthalmology. 2020;127;157-158.