Real-world solutions took center stage at this practical, punchy symposium on managing surgical dilemmas
From phaco in tiny pupils to IOL planning after LASIK, the APACRS 2025 Day 1 symposium Getting the Best Out of Difficult Situations, brought surgical grit and creativity to the spotlight. Moderated by Drs. Vishnu Patel and Darshin Bavishi, the session delivered hands-on solutions for navigating the kinds of tricky cases that don’t always follow the textbook. Here’s how eight surgeons brought clarity to complexity.
When 10 minutes just won’t cut it
Dr. Sanjay Gadre (India) opened the session with a message that many surgeons know too well: complexity takes time. As he puts it, “Patients may expect a 10-minute cataract surgery—but complex cases demand time, planning and precision.” He highlighted high-pressure situations like shallow chambers, pseudoexfoliation and white cataracts with lens-induced glaucoma.
In such scenarios, he recommended the use of pars plana trocar cannulas to stabilize the chamber, assist with rhexis formation and compartmentalize the vitreous. For zonular instability, CTRs (capsular tension rings) and three-piece IOLs were essential tools, not optional accessories. His rapid-fire walkthrough of strategies emphasized that success starts with anticipation and ends with intraoperative flexibility.
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No rings, no stretchers, no problem
When faced with a stubbornly small pupil, many surgeons instinctively reach for rings or stretchers. Dr. Jagdish Rana (India) instead demonstrated how careful technique and thoughtful sequencing can often eliminate the need for mechanical expanders.
His strategy begins with trypan blue to improve visualization, followed by the use of high-viscosity OVDs (ophthalmic viscosurgical device) and intracameral agents to coax the pupil open. A controlled capsulorhexis at the pupillary margin and early IOL implantation then help stabilize the chamber and prevent further miosis. Hydrodissection is performed gently and in multiple quadrants to minimize stress on the iris.
As Dr. Rana put it, “With patience and proper technique, most small pupil cataracts can be managed safely—without mechanical expanders.” By preserving iris architecture and reducing costs, his low-tech approach proved that finesse often trumps hardware in difficult cases.
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Finding the sweet spot at 60 cm
With more patients living at arm’s length from their screens, Dr. Divyang Brahmbhatt (India) focused on the importance of intermediate vision at 60 cm. He explained that not every trifocal IOL is equally effective at this range, making lens choice critical for digitally active patients.
His preferred platform, derived from Alcon’s PanOptix design, incorporates a 3.25 D near add and 2.17 D intermediate add within a 4.5 mm pupil zone. These specifications, he said, help approximate youthful visual function while keeping dysphotopsias to a minimum. Clinical results have shown 96% spectacle independence and reliable rotational stability with this design.
As Dr. Brahmbhatt noted, “Today’s patients want sharp vision at 60 cm—that’s the intermediate sweet spot—and not all trifocals get you there.” For patients who expect strong performance across distances, he argued, intermediate clarity is as important as near or far.
Safety at your fingertips
Digital tools are beginning to play a larger role in refractive surgery, and Dr. Girish Jethwa (India) introduced one designed to make LASIK screening safer. His LASIK Safety Calculator is a lightweight Android app that gathers inputs including refraction, keratometry, pachymetry and optical zone size, then calculates ablation depth, percent tissue altered and residual stromal thickness. If any safety thresholds are exceeded, the app issues automatic alerts.
The program also stores topography and aberrometry images, generates printable reports and enables easy sharing for second opinions via WhatsApp. Though it is temporarily unavailable on Google Play, the APK can be requested directly.
As Dr. Jethwa explained, “When the patient’s waiting and the surgeon is busy, any team member can plug in the data and instantly know if LASIK is safe.” He added that it remains the only comprehensive LASIK safety calculator currently available worldwide.
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When the machine says yes, but your gut says no
Screening algorithms have become central to refractive surgery planning, but Dr. Mohak Shah (India) cautioned that they cannot replace clinical judgment. He presented several cases where patients passed automated safety checks yet went on to develop complications. One example was a post-LASIK ectasia that appeared three years after surgery, despite all preoperative parameters reading as normal.
Dr. Shah explained that subtle clues like inferior skewing or small white-to-white diameters can slip under the radar of even the best systems. In these borderline situations, he urged surgeons to slow down, revisit the basics of topography and choose more conservative strategies.
“Machines are there to help you—but they don’t make the final call,” he reminded the audience. For cases with doubt, he recommended surface ablation over LASIK, noting that this approach protects the cornea and spares both surgeon and patient from sleepless nights.
Precision without the price tag
For surgeons who find digital toric alignment systems prohibitively expensive, Dr. Jagdeep Kakadia (India) introduced LAZOREX, a near-UV laser marking device designed to offer comparable accuracy at a fraction of the cost. The system, as presented by Dr. Kakadia, creates epithelial dash marks with 1° precision, visible for up to 12 hours and requires no ink or contact. The marks are painless, leave no scarring and can be applied before or during surgery without affecting comfort.
LAZOREX, according to Dr. Kakadia, has already been used in more than 9,000 cases across nine centers, with accuracy shown to match that of high-end digital systems. Its modular design can even integrate a 4K video camera, turning a standard slit lamp into a photodocumentation tool. As Dr. Kakadia explained, “LAZOREX gives you 1° axis precision, no ink, no pain, no scarring—and the marks last up to 12 hours.”
Cracking the code after LASIK
OL power calculation in post-refractive eyes is among the most challenging tasks in cataract surgery, especially when pre-op data are missing. Dr. Priyadarshi Asnani (India) reviewed the latest tools, including calculators from ASCRS, APACRS and ESCRS, and emphasized the importance of consistent, repeatable biometry from more than one device. Inputs such as axial length, white-to-white and topography across multiple diameters are critical to achieving reliable results.
He also offered practical guidance on lens choice: aspheric IOLs after myopic LASIK, non-aspheric IOLs after hyperopic LASIK and careful case selection for highly irregular corneas. Dry eye management and expectation-setting, he cautioned, are just as important as the calculations themselves. As Dr. Asnani noted, “If you enter clean, consistent data into modern calculators, you’ll land surprisingly close to the target—even without pre-op LASIK records.”
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Phakic IOLs, reimagined
Closing the session, Dr. Aditya Desai expanded the role of phakic IOLs beyond routine myopia correction. He shared challenging cases, from -29 D myopia managed with staged bioptics to customized lenses for patients with keratoconus or even pseudophakia after childhood cataract surgery, where phakic implants provided solutions traditional approaches could not.
In presbyopic patients, he highlighted the EVO Viva EDOF phakic IOL (STAAR Surgical, California, United States), which extends depth of focus to deliver both near and distance vision without sacrificing the natural lens. Across his examples, he emphasized that phakic IOLs combine versatility, reversibility and precision tailoring to individual anatomy.
“Phakic IOLs aren’t just for myopes—they’re a customizable, reversible tool that can rescue refractive cases other options can’t touch,” he said, underscoring their growing role in complex, high-demand patients.
Beyond the algorithm
The symposium revealed refractive surgery at its most dynamic, from managing small pupils without hardware, to dialing in trifocals at the 60 cm sweet spot to pushing phakic IOLs into territory once off-limits. Digital tools like LASIK safety apps, AI-driven IOL calculators and LAZOREX showed how innovation can sharpen accuracy without inflating costs.
Yet amid the tech, speakers stressed the timeless truth that machines assist, but surgeons decide. Preparation, adaptability and surgical instinct are the bedrock of success. The field’s future is not only high-tech but also highly human. And ready for the next wave of complex cases.
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Editor’s Note: The 37th annual meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2025) is being held from 21-23 August in Ahmedabad, India. Reporting for this story took place during the event. This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.