UI refresh — reorganized data entry, live abnormal-value flagging, new brand mark. Clinical logic unchanged since v0.27 (reading-habit question, undercorrection target strategy, per 2.4).
Surgeon-facing IOL platform screening module — biometry, corneal astigmatism, ocular pathology, refractive surgical history, and patient lifestyle/personality profiling feed a candidacy screen across monofocal, toric, EDOF, multifocal/trifocal, and light adjustable lens platforms. Facilitates — does not replace — surgeon judgment.
Module of the P.R.I.S.M. suite · pairs with pre-op refractive screening
Reading / sustained near workComputer & screensFrequent night drivingGolf / outdoor sportsCrafts / needlework / detail hobbiesFishing / huntingFrequent travelOther
Personality & Tolerance Questionnaire
Right Eye — OD
IOLMaster / Optical Biometry
Axial length >26 mm — high axial myopia (Clarification 2.2). Package A eligibility hinges on these two criteria:
Axial length <22 mm — high hyperopia (Clarification 2.3). Key concern: rule out refractive amblyopia (see Ocular Pathology — Other below) before proceeding with Package A.
⚠ Prior RK: keratometry and IOL power prediction are unreliable — expect diurnal refractive drift; diffractive multifocal not advised; consider intraoperative aberrometry, multiple formula averaging, and light adjustable lens.
NoneAmblyopia — refractiveAmblyopia — strabismicGlaucomaPseudoexfoliation / zonular weaknessCorneal dystrophy / irregular astigmatismKeratoconus — fullKeratoconus — forme frustePrior corneal transplant (PK/DMEK/DSEK/DALK)Chronic severe dry eyeUveitis history
IOL Platform Candidacy — OD
Flags — OD
Left Eye — OS
IOLMaster / Optical Biometry
Axial length >26 mm — high axial myopia (Clarification 2.2). Package A eligibility hinges on these two criteria:
Axial length <22 mm — high hyperopia (Clarification 2.3). Key concern: rule out refractive amblyopia (see Ocular Pathology — Other below) before proceeding with Package A.
⚠ Prior RK: keratometry and IOL power prediction are unreliable — expect diurnal refractive drift; diffractive multifocal not advised; consider intraoperative aberrometry, multiple formula averaging, and light adjustable lens.
NoneAmblyopia — refractiveAmblyopia — strabismicGlaucomaPseudoexfoliation / zonular weaknessCorneal dystrophy / irregular astigmatismKeratoconus — fullKeratoconus — forme frustePrior corneal transplant (PK/DMEK/DSEK/DALK)Chronic severe dry eyeUveitis history
IOL Platform Candidacy — OS
Flags — OS
Clarification Needed — Package Structure
running log of cases that don't cleanly fit the current A/B/C/LAL/Traditional taxonomy
Resolved (Clarification 1.1): Toric-EDOF/toric-multifocal combination — confirmed as a genuine, separately-offered pathway. Package A astigmatism management now branches by magnitude: low astigmatism uses a concurrent LRI (existing cross-reference notes), high astigmatism (\u22651.0 D) uses the toric version of the EDOF/multifocal lens itself, distinct from Package C's LRI. Original note is preserved below for history: a working note for a low-myope case (astigmatic left eye) described addressing astigmatism with "Package C (monofocal or toric Vivity)" — that phrasing was a mislabel; the toric-lens pathway lives in Package A, never Package C, which per 1.1 is confirmed monofocal-only.
Confirmed by Clarification 1.3: uveitis history is a relative (not absolute) contraindication specifically for Package A — elevated CME risk (post-op and as a late complication) degrades vision quality more with EDOF/multifocal optics than monofocal. Matches how this was already built (caution, not a hard stop). 1.3 also confirms it does NOT disqualify from Package B/C astigmatism correction — now stated explicitly on those cards' reasoning rather than left as silent non-effect. Still open, not addressed by 1.3: does remote/quiescent uveitis really warrant the same caution as recent/active disease? Currently one flat flag either way.
Combined surgery, non-glaucoma cases — cataract + trabeculectomy is now handled explicitly (bleb-induced irregular astigmatism → toric caution). Cataract combined with other procedures same session (vitrectomy, corneal transplant, etc.) still has no general flag — worth a future round if these come up.
Severe-glaucoma EDOF reversal, extended by 1.4, rationale added by 1.5: an earlier case (severe bilateral glaucoma) had EDOF explicitly recommended over multifocal. A later formal policy document stated "severe glaucoma: no multifocal or EDOF," which was built as authoritative — EDOF/Multifocal (Package A) hard-blocked at severe glaucoma, astigmatism correction (Package B/C) unaffected. 1.4 extended this to moderate glaucoma too — "moderate to severe: Package A not offered" — reversing that same formal policy document's separate "mild-to-moderate: EDOF acceptable" line for the moderate case specifically. 1.5 then supplied the clinical rationale for the severe case specifically (not moderate): severe-glaucoma patients need maximum light reaching the retina, and diffractive optics (named explicitly — Vivity, PanOptix, Odyssey) split incoming light across focal points, reducing light to any single focus. That rationale is now cited only for severe in the card text; moderate still cites 1.4 without the light-transmission mechanism, since 1.5's text didn't extend it there — flag if it should. Also added: iDose as a third combinable glaucoma procedure alongside MIGS/trabeculectomy (was missing from the dropdown entirely).
Built from Clarification 1.2, two assumptions worth confirming: (1) Total corneal astigmatism is computed from Pentacam anterior + posterior astig/axis using generic power-vector (Thibos J0/J45) summation — not a specific nomogram (e.g. Barrett/Abulafia-Koch) — since 1.2 said "vector math" without naming one. (2) 1.2 only describes Pentacam as tiebreaker when IOL Master and Auto K disagree on classification; the case where they already agree but Pentacam's total corneal value disagrees with both isn't addressed by 1.2's text, so it's built as a review flag rather than an override. Flag either if that's not the intended behavior.
Built from Clarification 1.6, one deliberately left open: LRI is now excluded for prior LASIK/PRK corneas — extended to prior RK too per Ray's decision (same biomechanical concern), as lriExcluded. Package C's astigmatism correction for these patients now reads as wound placement (one of its two included techniques) rather than LRI, and the card renames to "Monofocal + Wound Placement" accordingly. Left open on purpose: Package A's (EDOF/Multifocal) concurrent astigmatism correction for these patients at LOW astigmatism (<1.0 D) — 1.1 only defined a toric-lens alternative for \u22651.0 D, and with LRI now excluded there's no stated mechanism at low magnitude for this population. Surfaced as a flag and in-card note rather than resolved either toward "toric at any magnitude" or "no concurrent correction" — needs a decision.
Built from Clarification 2.1, a removal not just an addition: C:D ratio previously auto-filled the glaucoma severity dropdown (mild/moderate/severe) as a placeholder, with a review note flagging it needed clinical confirmation. 2.1 confirms C:D is a RISK metric (\u22640.6 low, \u22650.7 high), not a severity measure — severity comes from visual field perimetry specifically. The auto-fill is removed entirely (not just re-caveated): C:D now only shows a risk readout, and glaucoma severity — which directly gates Package A per Clarifications 1.4/1.5 — must be set manually. Flagging since this removes behavior that shipped earlier, not just refines it. Also unresolved: 2.1 doesn't assign a risk label to the 0.6\u20130.7 exclusive gap — shown as "borderline" pending confirmation.
Built from Clarification 2.2, reverses an undocumented asymmetry: high axial myopia (now confirmed >26 mm, not a placeholder) previously hard-blocked Multifocal unconditionally while leaving EDOF unblocked for the identical criterion — no stated rationale for treating the two platforms differently. 2.2 clarifies the real determinant is myopic retinal degeneration specifically, evaluated the same way for both: present → Package A not offered (both EDOF and Multifocal now symmetric); absent → may still be a candidate, but ALSO requires a history of good best-corrected vision (glasses/contacts) to fully clear — added as two new fields in a conditional panel shown above >26 mm axial length (previously uncaptured entirely). Not-yet-assessed data on either field is treated as a caution, not an automatic pass or block. When both criteria are met, the practice's stated preferred approach (Vivity IOL, mini monovision target initially) is now surfaced specifically on the EDOF card, not Multifocal, since 2.2 names Vivity by name. Astigmatism correction (Package B/C) was already unaffected by axial length and stays that way. Flagged since removing the unconditional Multifocal block is a real behavior change on data that was already live.
Built from Clarification 2.3, mirrors 2.2's structure for the hyperopic end: axial length threshold confirmed (<22 mm, fixed from a ≤22 placeholder to strict <, matching "under 22 mm"). Amblyopia's Package A hard-stop was already generic (fed diffractiveHardStopBase before this clarification) — not narrowed to refractive-only, since 2.3 doesn't say strabismic amblyopia should stop mattering, just names the type most relevant to this workup context. New from 2.3: Package C stays unconditionally available with amblyopia present, but Package B (toric) now specifically requires a confirmed history of good best-corrected vision — added as a new field in a conditional panel (shown <22 mm), downgrading (not blocking) Package B when that history isn't yet confirmed. Without amblyopia, Package A is now explicitly framed as qualifying, with the stated preferred lens (multifocal, PanOptix/Odyssey, distance target OU) surfaced on the Multifocal card specifically — contrasting with 2.2's Vivity/mini-monovision preference on EDOF for the myopic case. One design choice worth flagging: "ruled out" amblyopia is inferred from the existing amblyopia chip being unselected, not a dedicated confirmatory field — unlike 2.2's tri-state (not-assessed/absent/present) for myopic degeneration. If the practice wants an explicit rule-out step distinct from "chip not yet clicked," that needs a decision.
Built from Clarification 2.4: low-myopia range (-0.75 to -2.50 SE) confirmed correct, no longer a placeholder — isHyperopic's own threshold (SE \u22650.50) is a separate, still-unconfirmed placeholder, not addressed by 2.4, so left flagged. New patient-level question added ("reads without glasses pre-op?") since 2.4 makes clear the SE range alone was only ever a proxy — the explicit answer now drives two things: (1) the existing Multifocal low-myopia caution, previously always inferred from SE alone, now softens or strengthens based on the confirmed answer (a confirmed "no" skips the caution's premise entirely, falling through to whatever other caution checks would otherwise apply — implemented carefully so it doesn't short-circuit night-driving/dysphotopsia checks that used to run afterward); (2) a new undercorrection target-strategy note added to all monofocal-family cards (Package B, C, LAL, standard monofocal) when reliance is confirmed — targeting near pre-op SE rather than plano, framed as a discussion point against full correction, not a directive either way, per 2.4's own "surgeon must weigh visual habits, not just refractive numbers."