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Perspective Cataract Surgery Adjustable IOLs—Disrupting the Refractive IOL Industry David F Chang Department of Ophthalmology, University of California San Francisco, San Francisco, CA, US A djustable intraocular lenses (IOLs) are uniquely poised to disrupt the refractive IOL arena for both cataract and refractive lens exchange patients. This is because they will not only improve refractive outcomes, but will dramatically enhance the patient experience as well. Patients will be able to postpone confusing decisions about refractive targets and objectives until they can preview them postoperatively. The unique benefit of being able to customize and “choose” their pseudophakic vision after the surgery will be understandable, desirable, and easily explained to family and friends. Keywords Adjustable IOL, refractive surgery, cataract surgery, toric or presbyopia correcting IOL, bilateral simultaneous surgery Disclosure: David F Chang is a consultant for RxSight, Powervision, J&J Vision, and Zeiss. No funding was received in the publication of this article. This article is a short opinion piece and has not been submitted to external peer reviewers. Authorship: All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship of this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: September 1, 2017 Piblished Online: October 20, 2017 Citation: US Ophthalmic Review, 2017;10(2):95–8 Corresponding Author: David F Chang, 762 Altos Oaks Drive, Los Altos, CA 94024, US. E: dceye@earthlink.net Harvard Business School professor Clayton Christensen popularized the concept of disruptive innovation to explain why the most successful companies eventually fail. While the leading companies continue to develop better and more expensive technology, they fail to anticipate a sea change in the way new technology will be used and incorporated into their business or field—the disruptive innovation. I believe that adjustable intraocular lenses (IOLs) are going to be the technology that ultimately disrupts the field of refractive IOL surgery for both cataract and refractive patients alike. Because both presbyopia and cataracts are normal aging conditions, the majority of patients eventually become refractive IOL candidates. Surgeons and their patients will welcome the improvement in refractive outcomes that adjustable IOLs will enable. Equally important, however, is how adjustability will transform the patient’s refractive surgical experience—how patients will decide what specific refractive outcome they want and how we will provide this to them. This is how adjustable IOLs are poised to disrupt the competition. Why have refractive IOL adoption rates been disappointing for the past two decades? Although they have been available in the US since the mid-1990s, adoption of multifocal and even toric IOLs has been surprisingly low. That the additional costs are not covered by insurance is not the only significant barrier to growth. Additional factors include: (1) our inability to deliver LASIK-like refractive outcomes, (2) side effects from diffractive presbyopia correcting IOLs, (3) lack of surgeon confidence in being able to satisfy most patients, (4) patient difficulty in understanding the value proposition, (5) lack of patient word-of-mouth endorsement, and (6) lack of referring doctor promotion of premium IOLs. Imagine if we could not enhance our LASIK patients and only had one “shot” at hitting emmetropia. Patient satisfaction, surgeon confidence, optometric endorsement, and positive patient testimonials would all suffer. However, many thousands of refractive IOL patients are left with tolerable but residual refractive error because the majority of cataract surgeons do not also perform LASIK. We all dread facing patients who are disappointed with their refractive outcome or are distraught by pseudophakic halos and starbursts. When technically perfect surgery was performed, this is particularly demoralizing and reduces surgeon confidence in recommending presbyopia correcting IOLs. Many optometrists who follow these dissatisfied patients over time develop a bias against multifocal IOLs. Predicting preoperatively which patients might be more forgiving as opposed to demanding or picky about their eyesight is an unreliable art. Even when patients are delighted and pleased following their surgery, they do not know how much of the benefit is due to the cataract removal versus their choice of IOL. Finally, ophthalmologists are perplexed by the frequent poor TOU CH MED ICA L MEDIA 95