Cornea-First Blended Toric Monofocal Targeting With Intentional Physiologic With-The-Rule Astigmatism: Binocular Summation And Biologic Tolerance To Enhance Contrast Sensitivity And Binocular Function Beyond Presbyopia-Correcting Iol Trade-Offs

To evaluate postoperative visual performance using a cornea-first refractive cataract strategy that integrates blended toric monofocal targeting with intentional mild residual with-the-rule (WTR) astigmatism. This approach is designed to physiologically expand depth of focus through controlled anisometropia and symmetric meridional blur while preserving monofocal optical quality. The strategy emphasizes total corneal power validation, corneal symmetry, and axis coupling relative to the visual axis, aiming to enhance contrast sensitivity and binocular function while avoiding the optical trade-offs associated with presbyopia-correcting intraocular lens platforms.

Laservision Ambulatory Surgical Unit, Athens, Greece and the NYU Grossman School of Medicine, Department of Ophthalmology, New York City, NY

Prospective observational case series of 250 consecutive patients (500 eyes) undergoing bilateral phacoemulsification with implantation of an aspheric hydrophobic acrylic toric monofocal IOL (Clareon CNW0T). IOL calculations incorporated swept-source OCT total keratometry (IOLMaster 700) and Scheimpflug-derived total corneal power referenced to the corneal vertex. Refractive targets: −0.40 to −0.50 D SE in the dominant eye and −1.25 to −1.50 D SE in the non-dominant eye, with planned residual WTR cylinder of 0.30–0.50 D. Mandatory preoperative contact lens simulation confirmed binocular tolerance. Primary outcomes at 3 months: binocular UDVA, UNVA, residual refraction, contrast sensitivity (photopic and mesopic), and spectacle dependence.

At 3 months, residual cylinder was ≤0.50 D in 85% of eyes and ≤0.25 D in 20%, reflecting both refractive precision and intentional physiologic WTR targeting. Binocular UDVA was ≥20/20 in 95% of patients, with 55% achieving ≥20/16. Binocular uncorrected near acuity was J2 or better in 85% of patients. Contrast sensitivity values remained within or above age-matched normative ranges across spatial frequencies under photopic and mesopic conditions. Complete spectacle independence reported by 70% of patients, without evidence of a distance acuity floor effect. Optical modeling of bilateral toric monofocal PSFs demonstrated preserved binocular summation and near stereopsis compared with theoretical bilateral trifocal or EDOF IOL configurations

Blended toric monofocal targeting with planned WTR astigmatism extends functional visual range through binocular summation while preserving or enhancing contrast sensitivity and robust binocular function. Interpreted in a cornea-based optical framework—incorporating validated total corneal power measurement, axis coupling awareness, and tolerance to biologic lens-position variability—this strategy restores physiologic total-eye optics without increasing intraocular optical complexity. Compared with presbyopia-correcting IOL designs, the approach demonstrates high biologic tolerance, stable contrast behavior, and preserved binocular integration, reframing refractive cataract surgery as a cornea-driven model prioritizing optical robustness.