Wavefront Automated Refraction Comparison of Three Different IOLs: Aspheric Monofocal and Two Enhanced Monofocal IOLs

The objective of this study was to compare subjective manifest refraction with wavefront-based automated refraction using iTrace (ray tracing) and LadarWave (Hartmann-Shack) in eyes implanted with two enhanced monofocal intraocular lenses (IOLs) and a standard aspheric monofocal IOL, emphasizing agreement and refractive variability across optical designs. This retrospective cohort included 84 eyes from 42 patients implanted with Tecnis Eyhance (DIB00), RayOne EMV (RAO200E), or Tecnis ZCB00 IOLs. Postoperative evaluation (1-3 months) included uncorrected and corrected distance visual acuity and subjective manifest refraction, followed by automated refraction with iTrace and LadarWave. Outcomes were sphere, cylinder, and spherical equivalent (SE). Agreement was assessed using mean signed difference, mean absolute error, root mean square error, Bland-Altman limits of agreement, proportions within clinically relevant thresholds, and vector astigmatism (J0, J45). Linear mixed-effect modeling evaluated SE differences across methods and IOL types while accounting for within-subject correlation. Subjective SE differed among IOLs (<i>p</i> = 0.027), with RAO200E more myopic than ZCB00 (-0.20 ± 0.32 D vs. -0.08 ± 0.44 D, <i>p</i> = 0.035). Automated refraction showed greater variability and poorer agreement in enhanced monofocal IOLs, particularly for cylinder and SE, with wider limits of agreement and fewer eyes within ±0.50 D compared with ZCB00. In mixed-effect contrasts (three-method repeated-measures model), iTrace and LadarWave showed a consistent myopic bias versus manifest refraction in DIB00 and RAO200E, whereas in ZCB00 the iTrace-manifest difference was not significant and LadarWave retained a significant myopic bias. Enhanced monofocal IOLs exhibit reduced agreement between wavefront-based automated and subjective manifest refraction compared with a standard aspheric monofocal IOL. Manifest refraction remains essential for postoperative assessment, and automated measurements should be interpreted as complementary, particularly in IOL designs that modify aberrations.