At the 2026 ASCRS meeting, Kavitha R. Sivaraman, MD, ABO; Michael E. Snyder, MD, ABO; and Dagny Zhu, MD, ABO presented “Premium IOLs in Imperfect Eyes 2026." Here, Drs. Sivaraman and Zhu share some key takeaways on selecting premium IOLs for patients with corneal pathology. The below transcript has been edited for clarity.
Kavitha R. Sivaraman, MD, ABO: My name is Kavitha Sivaraman. I'm a cornea and cataract doctor at the Cincinnati Eye Institute. I'm joined here today by my ASCRS 2026 co-instructor, Dr. Dagny Zhu from NVISION Eye Centers. And we're here to talk about our course, which was entitled “Premium IOLs in Imperfect Eyes, the 2026 Edition.” Thank you, Dagny for being here. This is our third iteration of this course, and it's been a really gratifying one to teach. The inspiration was really from my own origins as a cataract surgeon and being on my own in practice and being really hesitant to offer some of the more premium IOL options and not really having a full understanding of when I could use one of these premium technologies and when I should not. So this course is really designed to look at eyes that maybe are imperfect in some way, which in truth most are, and give some guidelines on when you can safely and ethically use some of these advanced technology lenses.
My portion focused mainly on corneal pathology, things like pterygia, Salzmann nodules, base membrane dystrophy and Dagny’s portion was mainly on post-LASIK, post-refractive corneas. So Dagny, can you give us a couple of pearls about approaching cataract surgery in eyes that have had prior LASIK or PRK or SMILE?
Dagny Zhu, MD, ABO: Yeah, so I'm a cataract and refractive surgeon, cornea trained, in a private practice in Los Angeles. So, I have a lot of refractive surgery patients in my clinic. They've had LASIK, PRK, RK, the whole spectrum, maybe 20 years ago. And now they're coming back because they have cataracts. So you need to know how to manage these patients. And I think this is such a wonderful course because it is so real world and it offers practical guidance on the real patients that you see in your daily practice. It's not like an FDA study where all the eyes are pristine. Of course, they have excellent vision. But in the real world, given the innovations we've seen, the technology nowadays, the presbyopia-correcting IOLs have come a long way. A lot of the myths that we’ve heard before, like, never put a premium IOL in an eye that's had LASIK before or PRK, I don't think that's true anymore. And I think it's a lot more nuanced. So we covered a lot of case-based examples of which eyes may still be suitable for a premium IOL, which type of premium IOL is suitable for different types of refractive surgery eyes. Are there several ones you want to use in post-myopic, which is post-hyperopic LASIK. The spherical aberration of the lens actually matters, whether it's positive or negative. The amount of area where astigmatism matters helps you to direct whether you should use a pinhole lens or maybe not. So there's just a lot of pearls that we gave during this course. And I thank Kavitha for putting it together and gathering all this faculty together to provide some real-world guidance.
Dr. Sivaraman: Absolutely. Thank you. So Dagny is just one of the all-star faculty, Michael Snyder, MD, ABO, previously Leo Kim, MD, PhD, provided perspective on advanced anterior-segment complexities as well as premium IOLs from the perspective of a retina specialist. My portion really focuses, again, on corneal pathology. And I think there are some guiding principles regardless of what you're dealing with, whether that's a pterygium or an irregular astigmatism from a scar. And that really is looking at patient expectations. Yes, sometimes a toric lens is not going to work as well when there's a component of irregular astigmatism, but there still might be a benefit over a standard IOL. As long as that patient's adequately educated and you have reproducible measurements, it may still be a great option. So, the approach to looking at premium IOLs in patients with imperfect corneas is really not all that different than how you would approach a patient with a normal cornea. You're going to look at what their expectations are, what the downsides of each given lens platform is. Look and see if your measurements are reproducible and make sure that some of the contraindications of the lens aren't total red lights for whatever that patient is looking for. For example, in a post-RK patient who has very, very irregular astigmatism, sometimes a toric lens can help if it's regular to a degree, but a multifocal IOL you're probably not going to get away with. So we really dig into when it is possible and plausible to use one of these advanced-technology lenses in a patient with a complex cornea and what you can expect.
Dr. Zhu: And just to add to that, I think topography was a key part of this course. It's all about looking at the topography. And we went over a lot of keys to look at or pearls to look at, including what is the higher-order aberrations in the central 4 mm? What is the spherical aberration of the cornea? So all of that will help to guide you, especially again, in post-refractive eyes, what's the best type of premium IOL, what can the patient expect? And at least for this patient population, I find that they're the most “unrealistic,” meaning they want it all. They have perfect vision after their LASIK 20/20, and they want still perfect vision after the cataract surgery, 20/20, far and close. And there are some ways to deal with it and offer that today with the technology available.
Dr. Sivaraman: Absolutely. The other thing that we go over are the newer types of lenses that not all surgeons may have experience with yet, small-aperture IOLs, light-adjustable IOLs, and the newest forms of extended depth of focus and multifocal IOLs, and when you could use those and be reasonably sure that you're going to get good results. Thanks for joining us today.