The 5 Ws of Post-Presbyopic IOL Enhancement

To achieve optimal results with post-presbyopic IOL enhancement, it is important to understand the ‘five Ws’ of enhancement: who should perform it, why it should be done, what amount of correction should be entered and when, and where or how it should be performed, Francesco Carones MD advised.

Dr Carones underlined the role of the refractive or vision-corrector surgeon, explaining it would be better if the one performing the procedure implemented the original treatment. He believes the surgeon should understand the problem, quantify the magnitude of correction, choose the most appropriate procedure, and decide the timing for the enhancement.

Achieving a mandatory perfect refractive result is important for Dr Carones mainly because patients are becoming increasingly demanding—although he noted most of them did pay a ‘premium fee,’ thus expecting the best possible outcome. Presbyopia-correcting IOLs, however, come with many issues. Diffractive optics, for example, are not forgiving at all. Refractive optics tend to be more forgiving but provide less range of focus, which may not be wide enough. Moreover, night dysphotopsia amplifies when the light does not focus on the macula.

What to correct—or how much to correct—may be critical, so Dr Carones stressed always focusing on the purpose behind enhancing. He advised surgeons to ensure the patient really understands the advantages and disadvantages of getting close to the target via an intervention. Astigmatism over -0.75 D sphere should be considered for correction as a critical amount, especially when implanting diffractive optics, so it is advisable to speak with the patient about the advantage of correcting residual refractive error, he said.

When dealing with enhancement, the two variables to consider are the amount of astigmatism and the visual axis. If the sphere equivalent is plano but the axis is wrong, an enhancement should be considered as soon as possible, Dr Carones explained. When the amount is wrong both with and without a wrong axis, it might be necessary to wait for refractive stability. When there are three variables, like amount, axis, and sphere, it is always recommended to wait for refractive stability, he added.

But for how long? The majority of the many variables to consider relate to the healing process. Dr Carones observed it might be advisable to wait a month for the refractive stabilisation before opting for an enhancement. Figuring out how to proceed is the final decision, which he described using his personal decision tree: (1) start with the IOL rotation; if this is not a good option, then use (2) LASIK; if even this is not a good option, try (3) PRK, followed by (4) supplemental IOL and (only if any of the above are indicated) IOL exchange.

“Dealing with presbyopia-correcting IOLs frequently deserves a fine tuning. The amount of correction, timing, and the appropriate procedure are all critical to achieve this best result,” he concluded.

Dr Carones spoke at the 2025 ESCRS Winter Meeting in Athens.

Francesco Carones MD is Medical Director and Physician CEO at the Advalia Clinic of Milan, Italy.