Influence of Posterior Capsulotomy Size on Visual Quality and Patient Satisfaction with Extended Depth-of-Focus IOLs.

Purpose: Prior studies in monofocal intraocular lenses (IOLs) suggest that larger Nd:YAG posterior capsulotomies may reduce straylight and photic phenomena, but generalizability to extended depth-of-focus (EDOF) optics is uncertain. We evaluated whether capsulotomy size affects optical quality, higher-order aberrations (HOAs), and patient-reported outcomes in eyes with EDOF IOLs. Patients and Methods: In this prospective single-center study, 106 pseudophakic eyes with visually significant posterior capsule opacification and EDOF IOLs underwent Nd:YAG laser posterior capsulotomy. Capsulotomy size was measured at the slit lamp using a calibrated reticule in the horizontal and vertical meridians; the effective diameter was defined as the mean of these two measurements. Eyes were prospectively assigned to a small opening (S group, n=47), created to slightly exceed the IOL's central diffractive zone (≈1.6-1.8 mm), or a large opening (L group, n=59), extended to the margin of the outermost diffractive ring (≈4 mm). At 1-month post-treatment, visual acuity, HOAs, defocus curves, and optical quality metrics were assessed. Subjective outcomes were evaluated using the APPLES and Catquest-9SF-CN questionnaires. Results: Both groups showed improved visual acuity, with greater corrected distance visual acuity (CDVA) gain in the L group (-0.15 vs -0.06 logMAR; P = 0.024). Trefoil aberration increased more in the S group than in the L group (+0.15 vs +0.02; P = 0.021), while spherical aberration decreased more in the S group than in the L group (-0.20 vs -0.09; P = 0.024). The APPLES questionnaire showed a greater reduction in starburst severity and frequency in the L group (Δ -0.43 vs +0.07; P = 0.010). Multivariate analysis identified pre-treatment spherical equivalent, trefoil, mesopic pupil size, and CDVA as significant predictors of satisfaction. Conclusion: Capsulotomy size significantly influences optical quality and patient satisfaction in eyes with EDOF IOLs. Larger openings improve CDVA and photic symptoms, while smaller ones better reduce spherical aberration but increase trefoil. Personalizing capsulotomy size may optimize outcomes.