Intraocular lens exchange and pars plana vitrectomy for missed refractive target and myodesopsia

A 63-year-old woman presented with an ocular history of myopic laser in situ keratomileusis (LASIK) in both eyes and a retinal tear in the right eye years ago. She was pseudophakic with a Trulign (Bausch & Lomb, Inc.) silicone intraocular lens (IOL) and near aim in the right eye. She presented with blurred vision, loss of depth perception, and a visually significant cataract in the left eye. She had been using a monovision strategy, and the left eye was her dominant eye. Unfortunately, she could not wear contact lenses as she had severe dry eye from autoimmune disease, and the bridge of her nose would not tolerate spectacles. Her biggest frustration was that she was an extremely active swimmer and surfer and could not see distance during these activities. On initial examination, pertinent findings included a manifest refraction of −1.75 −0.50 × 089 with a CDVA of 20/20 in the right eye and +1.25 −0.50 × 094 with a CDVA of 20/40-2 in the left eye. Pupils, extraocular motility, and confrontation visual fields were normal. Glare simulation with brightness acuity tester was 20/150 in the left eye. She had well-healed LASIK flaps without epithelial ingrowth, debris, or striae; dilation size was 8 mm in both eyes; and she had a Trulign silicone posterior chamber IOL with lens pitting and an open capsule in the right eye and a 2-3+ opalescent nuclear sclerotic cataract in the left eye. On dilated examination, she had a cup-to-disc ratio of 0.65 in both eyes with normal maculas and vessels. She had laser retinopexy around a horseshoe tear in the superotemporal quadrant of the right eye and a posterior vitreous detachment (PVD) in the left eye. In the left eye, she had a partial PVD without evidence of lattice or other retinal pathology. Corneal topography and tomography are shown in Figure 1 JOURNAL/jcrsoc/04.03/02158035-202501000-00031/figure1/v/2025-05-12T174843Z/r/image-tiff and Supplemental Figures 1–4 (available at http://links.lww.com/JC9/A405). The patient was motivated for surgery in the left eye because of anisometropia, glare, and blurred vision. She underwent uncomplicated cataract surgery in the left eye, and an LI61A0 silicone 3-piece IOL (Bausch & Lomb, Inc.) was chosen as she was happy with the optics of the silicone lens in the right eye. She was offered the light-adjustable lens (LAL) for increased accuracy in postlaser vision correction eyes. However, she declined because of the longer postoperative time to completion. A long discussion of risks, benefits, and alternatives between her retina doctor and the patient was held regarding silicone IOL choice given her history of retinal tear in the right eye. Unfortunately, she had a refractive surprise of −1.00 diopter (D) because of the inaccuracy of postlaser vision correction IOL calculations and was extremely frustrated with the outcome. She also developed a visually significant posterior capsule opacification, and a YAG posterior capsulotomy was performed in the left eye. Last, she complained of a constant cloud that was blocking her central vision (Figure 2) JOURNAL/jcrsoc/04.03/02158035-202501000-00031/figure2/v/2025-05-12T174843Z/r/image-tiff . How would you address this refractive miss? What additional diagnosis would assist in your decision making? What interventions, if any, would you recommend for her visual discomfort?