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impact of residual refractive error in terms of patient satisfaction and visual acuity and quality. Dr. Schallhorn and his colleagues at Optical Express took 2,485 consecutive patients who had bilateral refractive lens exchange (4,970 eyes). Each patient had a one-week interval between first and sec- ond eyes, was implanted with a multifocal lens, and was asked to respond to a patient questionnaire at one month. The average age of the patient population was 57.5±7.5 years old, with younger patients who had high refractive error or cataract. Most of the treatments fell in the hyperopic range (84% of study patients), but as a whole the study included a wide range of treatments, with the mean spherical equiv- alent (MSE) of myopes at –3.89±2.97 D, hyperopes at +2.36±1.68 D (overall preop MSE +1.37±2.94 D); average preop cylin- der was 0.64±0.48 D. To address astigmatism, astigmatic keratotomy was performed for astigmatism between 1 and 1.5 D, and toric lenses were implanted for astigmatism more than 1.5 D. About 70.6% of patients achieved 20/20 uncorrected distance visual acuity monocularly; postop, MSE was +0.05±0.47 D, cylinder 0.45±0.41 D—"very reasonable results for refractive lens exchange in this target population," said Dr. Schallhorn. Dr. Schallhorn and colleagues also stratified the postop spherical equivalent by the percentage of patients who achieved 20/20 distance visual acuity. In patients stratified by 0.5 D MSE, patients with MSEs closer to zero were much more likely to have 20/20 distance visual acu- ity—80.3% of patients with 0.0 D spherical equivalent achieved 20/20. However on analysis, somewhat surprising to Dr. Schallhorn, a difference of even just 0.5 D MSE resulted in a dramatic drop in the percentage of patients achieving 20/20— only 62.5% of patients with +0.5 D and 57.1% of patients with –0.5 D MSE achieved 20/20 vision. Postop cylinder also affected chances of achieving 20/20 visual acuity: 82.3% of patients with 0.0 D of postop cylinder achieved 20/20; in comparison, only 74.5% of patients with 0.5 D postop cylinder and 54.3% of patients with 1.0 D postop cylin- der achieved 20/20. At 1.5 D of postop cylinder, only 26.5% of patients achieved 20/20. But the "real outcome metric" Dr. Schallhorn and his colleagues were inter- ested in was patient satisfaction. "I believe, certainly in the refractive lens exchange or laser vision correction patient—elective procedures—that the patient's satisfaction comes second only to complications as far as the most important outcome metric," he said. Patient satisfaction at their clinic was very high—94.1% were satisfied based on a 5-point scale from very satisfied to very dissatisfied; 1.6% were dissatisfied, and 4.2% were neither satisfied nor dissatisfied. 3 Dr. Schallhorn and his colleagues also stratified the outcome data against patient satisfaction. Again, there is a striking rela- tionship between residual postop MSE and cylinder and satisfaction, with 70.8% of patients with 0.0 D postop MSE and 73.2% with 0.0 D postop cylinder saying they were very satisfied. Although Dr. Schallhorn and his col- leagues achieved good unaided vision and a high level of patient satisfaction in their patients receiving bilateral premium multi- focal IOLs, ultimately they found that to Incremental amounts of residual sphere and cylinder impact the patient's ability to achieve 20/20 vision and high levels of satisfaction.

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