Lenticular refractive surgery is more powerful than corneal refractive surgery for the treatment of large refractive errors. With refractive lens exchange (or cataract surgery) we can treat huge degrees of hyperopia and myopia as well as astigmatism. For younger patients with a large degree of myopia, a phakic IOL is a better option since it retains the clear human crystalline lens. This maintains the patient’s accommodation and also avoids the retinal risks associated with pseudophakia. Our guest surgeon does a great case of implanting the new Evo Visian ICL in this patient with high myopia. This newer design has a flow through hole in the center of the optic which avoids the need for a peripheral iridotomy such as with the prior iterations. This may also help keep the optic of this phakic IOL properly vaulted above the crystalline lens to lessen the risk of cataract formation. As surgeons, we are always happy to add more tools to our surgical toolbox so that we can offer all patients a tailored approach best suited to their needs and anatomy.