Predicting Postoperative Visual Acuity With Different Intraocular Lenses Using Preoperative Visual Simulations In Patients With Cataracts

Selection of IOLs remains challenging due to the difficulty of predicting postoperative visual performance before surgery. SimVis technology enables binocular see-through simulation of different IOL designs, allowing patients to experience multifocal vision preoperatively. Prior work has demonstrated that SimVis accurately simulates IOL visual performance and can be used in patients with cataract. However, the presence and severity of cataract may affect the predictive accuracy of preoperative simulations. The purpose of this study was to evaluate the relationship between preoperative SimVis simulations and postoperative binocular VA in cataract patients to determine whether accounting for cataract severity improves postoperative prediction

Instituto de Microcirugía Ocular (IMO), Barcelona, Spain.

Fifty-three patients undergoing bilateral cataract surgery with monofocal, EDOF, or trifocal IOL implantation were included. Before surgery, binocular VA at far, intermediate and near distances was measured through SimVis simulations of different IOL designs. The implanted IOL was selected independently by the surgeon. Postoperative binocular visual acuity was measured at least 1 month after surgery and compared with the corresponding preoperative simulation of the implanted lens. Agreement between simulated and postoperative vision was evaluated using Bland-Altman analysis, and prediction accuracy was assessed after adjustment for cataract severity and IOL type using multivariable linear regression and a predictive calibration model.

As expected due to cataracts, preoperative SimVis simulations underestimated postoperative visual acuity at all distances, particularly at intermediate and near vision. After adjustment for cataract severity and implanted IOL type, agreement between simulated and postoperative vision improved substantially. Prediction accuracy after adjustment showed that 98% of eyes predicted within ±2 lines of postoperative VA for far, 87% within ±2 lines for intermediate, and 77% within ±2 lines for near distance. Mean absolute prediction error decreased from 0.16 to 0.05 logMAR at far, from 0.23 to 0.13 at intermediate, and from 0.27 to 0.13 at near vision. Systematic bias observed preoperatively was largely eliminated after adjustment.

Preoperative SimVis visual simulation provides clinically meaningful predictions of postoperative binocular visual acuity after cataract surgery. Although cataract opacity before surgery systematically introduces underestimation of VA through simulated vision, calibration models accounting for cataract severity and IOL type significantly improve predictive performance. These findings support the use of SimVis as a quantitative preoperative tool for managing patient expectations and assisting personalized IOL selection.