Debate, data and drama. APACRS 2025 brought cataract controversies to life in the spotlight.
On Day 2 of the 37th annual meeting of the Asia-Pacific Association of Cataract and Refractive Surgeons (APACRS 2025) in Ahmedabad, India, the joint symposium of APACRS, LATAMSCRS and ESCRS put controversy at center stage. The session—fittingly titled Masters Don’t Always Agree!—brought together global leaders to test each other’s views on some of the biggest open questions in cataract and refractive surgery.
“We want different perspectives and real discussion,” said co-chair Prof. Burkhard Dick (Germany) as he opened the session. And that’s what unfolded: sharp arguments over immediate versus delayed bilateral cataract surgery, whether presbyopia is best treated in the eye or on the cornea, and how to handle low astigmatism—toric IOLs or corneal incisions.
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Immediate vs. delayed sequential cataract surgery
The session opened with a showdown between Prof. Dr. Claudette Abela-Formanek (Austria) and Prof. Dr. Graham Barrett (Australia).
Prof. Abela-Formanek made the case for Immediate Sequential Bilateral Cataract Surgery (ISBCS), defining it clearly: “It means same-day cataract removal in both eyes of a patient, under two separate surgeries.” She emphasized strict aseptic protocols, intracameral antibiotics and abandoning the second eye if complications arise in the first.
Her argument was compelling: faster visual recovery, no anisometropia between surgeries, lower hospital costs, reduced carbon footprint, and above all, patient preference. “A study from Copenhagen showed that 94% of patients preferred immediate cataract surgery as opposed to delayed… many said they would still choose it even if they had a small refractive error,” she noted.
But Prof. Barrett wasn’t convinced. “For me, I would not want to compromise the safety or the outcome of cataract surgery in any way for the sake of convenience or costs,” he countered. He cited rare but devastating case reports of bilateral endophthalmitis, cystoid macular edema risk and the loss of an opportunity to optimize the second eye based on first-eye results.
He also highlighted lost opportunities in refractive fine-tuning: “You definitely can improve outcomes in the second eye by using the refractive outcome in the first eye… and you forego that with immediate surgery. I do a lot of monovision, and monovision works best if you can be certain the first eye has your desired outcome.”
The room divided—some nodding to patient convenience, others firmly anchored in safety-first caution. It was the perfect microcosm of the session’s spirit: strong cases on both sides, no easy answers.
READ MORE: APACRS 2025 Tackles Tough Cases in Cataract and Refractive Surgery
Presbyopia correction: In the eye vs. on the eye
Next came a spirited exchange between Dr. Takashi Hida (Brazil) and Prof. Dr. Sri Ganesh (India).
Dr. Hida championed “in the eye” approaches—multifocal, trifocal and blended IOL strategies, supported by a portfolio of randomized studies. He reminded the audience, “Patient expectation is everything. Under-promise, over-deliver.” His studies comparing bilateral Alcon’s (Geneva, Switzerland) PanOptix IOL, Johnson & Johnson’s (New Jersey, US) TECNIS Synergy IOL and blended approaches showed robust outcomes across distances.
But Prof. Ganesh flipped the perspective. With a touch of humor, he quipped about his younger colleague: “Look at him—he’s a teenager. What does he know about presbyopia? He doesn’t even have grey hair.” Laughter filled the hall, but his argument was serious: the cornea is where precision lies.
“At one year, the mean spherical equivalent was +0.13 in the dominant eye and -1.42 in the non-dominant. That kind of accuracy, laser gives you. Not even the best formulas can deliver that with IOLs,” he said.
For Prof. Ganesh, corneal-based presbyopia correction avoids the irreversible risks of intraocular surgery. And in a dramatic flourish, he shared his personal story: “Ten years ago, I underwent corneal presbyopia correction myself. Today, I still read the smallest print on the vial, J1, uncorrected. Why remove clear lenses when they are functional?”
The takeaway is that the future of presbyopia correction may be personalized—sometimes “in the eye,” sometimes “on the eye.”
READ MORE: Presbyopia on the Table: What Works, What’s Next
The astigmatism divide: Corneal cuts vs. toric iOLs
The final debate pitted Dr. Shail Vasavada (India) against Dr. Artemis Matsou (Greece).
Dr. Vasavada spoke first, making a case for corneal incisions and astigmatic keratotomy (AK)—particularly in low astigmatism cases. He showed how a femtosecond laser allows precise trapezoidal wound construction, reducing distortions and enabling titratable corrections. “If you have 0.5 diopters or more, it matters—even small astigmatism affects reading speed and contrast,” he reminded the audience.
But Dr. Matsou came armed with data. “We now have strong clinical evidence to suggest toric lenses should be the preferred option—even for low levels of astigmatism.”
She cited a recent landmark study published in the Ophthalmology journal: “More than 40,000 eyes… and patients in the incision group were nearly three times more likely to not achieve less than 0.5 diopters of residual astigmatism. For 1.25 to 1.5 diopters, the risk was five times higher. Toric lenses are more accurate, more reliable—regardless of axis or magnitude.”1
And what about the cost? As Matsou pointed out, patients themselves put value on outcomes: ‘Yes, toric lenses may cost more, but patients were willing to pay an average of 451 Euros for a 10% higher chance of achieving 20/20. That tells you all you need to know.’”
In the end, the room was left weighing two perspectives—Dr. Vasavada’s pragmatic call for AK as a flexible, accessible tool, and Dr. Matsou’s evidence-driven case for toric lenses as the more predictable path.
WATCH NOW: ESCRS Toric IOL IME Video Interview Series
A session that embraced disagreement
By the end, the hall buzzed with the rare electricity of true academic debate. No single “winner” emerged, but that was never the goal. As Prof. Dr. Barrett said in closing: “Not every change is for a good thing. But we need these discussions.”
The symposium showcased what makes ophthalmology extraordinary. There are multiple ways to achieve optimal outcomes, each shaped by patient needs, surgeon philosophy and global realities.
From ISBCS versus delayed surgery, to IOL versus corneal presbyopia correction, to incisions versus toric lenses, the message was clear—masters don’t always agree, but their disagreements fuel innovation, refine practice, and ultimately, elevate patient care.
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.
Reference
- Schallhorn SC, Schallhorn JM. Comparison of Surgical Methods for the Correction of Low Amounts of Corneal Astigmatism during Cataract Surgery. Ophthalmology. 2025:S0161-6420(25)00360-4. [Epub ahead of print].