Finding the root cause of a patient’s dissatisfaction and knowing how to fix the problem can turn an upset patient into a happy patient.
While there are many possibilities that can explain patient dissatisfaction after having a refractive IOL implanted, in the overwhelming majority of cases (>90%), I have found the patients had unrealistic expectations.
Although physicians explain the limitations of current IOL technology, and the patient may even sign a consent detailing their understanding of this, this does not necessarily mean the patient has a good understanding of what is to occur. Many times after the patient has mentioned decreased dependence on spectacles, the patient immediately drifts off – imagining superhuman-like vision. Complicating matters are industry sponsored literature that may also falsely elevate patient expectations. Therefore it is important with any patient who is about to undergo cataract surgery with implantation of a refractive IOL is told on two separate occasions what they can realistically expect.
If the patient has predisposing risk factors that may limit outcomes such as pseudoexfoliation syndrome, the patient should be fully educated about this condition. As always, one should try to under promise and over deliver. In some cases there are organic causes that may limit success of the refractive IOL, and this article will focus on treatment for those entities.
For accommodating IOLs, patient complaints may include limited reading ability and/or z-syndrome. Fortunately, this latter case has become almost nonexistent with the later generation lenses. However, one should always be suspicious in cases of increasing astigmatism that does not correlate with topography. To minimize risk, the capsulorhexis should be on the larger size and both haptics should be confirmed to be within the capsular bag. If a ‘Z’ syndrome has occurred in spite of this, careful use of a YAG laser to extend a capsulotomy under the haptic-optic junction can restore a planar position.
In cases of limited reading ability, cycloplegic refraction should be performed. Often these patients are mildly hyperopic and using their accommodative ability to reach plano. Piggyback lenses or laser vision correction can cure these cases. In addition, many surgeons will target some myopia in the non-dominant eye to expand the range of uncorrected vision.
For the multifocal IOLs, complaints tend to focus on glare/haloes and/or “Vaseline vision.” In these cases several items should be checked. I once heard these described by Dr. Eric Donnenfeld as the 6 C’s and they include:
Cylinder – For multifocal intraocular lenses to function properly, the optical system must be perfect. Residual astigmatism can greatly decrease their performance. Laser vision correction can always be effective. However, if the spherical equivalent of the refractive error is plano, limbal relaxing incisions can also be performed. www.lricalculator.com is an excellent free resource available to surgeons that can be used pre or post cataract surgery to minimize corneal astigmatism.
Cornea – The tear film can be the most important refractive part of the eye, and instability may also diminish performance of a multifocal lens. In fact, it has been shown that patients (without dry eyes) who were placed on cyclosporine for two weeks pre-operatively and three months post-operatively had better quality of vision and more ocular comfort.1,2
Capsule – Posterior capsule opacification can be quite disabling in even mild forms when in the context of a multifocal lens. That said, one should always be certain that the PCO is significant, for if an IOL exchange is being considered it will be more challenging technically with an open capsule.
CME – Cystoid macular edema may not be clinically evident, and so macular OCT should be performed on any dissatisfied multifocal IOL patient. It is quite possible that a patient with 20/20 uncorrected vision can have CME, and treatment of it is required to maximize quality of vision. Topical steroids and NSAIDs can be employed, but in longstanding cases of CME intravitreal therapy may be required.
Centration – Often the reason for “Vaseline vision” after cataract surgery with a multifocal lens is that in many cases the lens is perfectly centered within the capsular bag but the patient has a large angle kappa. Intraoperative centration is critical. However, postoperative intervention is a possibility. Laser iridoplasty to recenter the pupil over the central optic has been shown to improve visual acuity, but this can only be entertained in mild cases of decentration.
Crazy – Whether the patient has supratentorial issues or the physician was crazy to think the patient was a suitable candidate, the multifocal lenses are not for everybody. When it appears that nothing will satisfy the patient, a lens exchange surgery should be offered. While monofocal vision may not ameliorate all their symptoms, the patient will no longer feel that the lens is the source of their problems.
Ultimately, whether accommodating or multifocal lenses are used, not all patients will be satisfied in the immediate postoperative period. Addressing patient concerns and treating causes of decreased vision will greatly improve patient satisfaction and practice growth. In some cases, you may desire to have the patient seek second opinion prior to any intervention.
- Donnenfeld E, Roberts C, Perry H, et al. Efficacy of topical cyclosporine versus tears for improving visual outcomes following multifocal IOL implantation. Paper presented at: The ASCRS/ASOA Symposium on Cataract, IOL and Refractive Surgery; April 2006; San Diego, CA.
- Donnenfeld ED, Perry HD, Wittpen J Jr, et al. Cyclosporine on quality of vision in patients undergoing IOL implantation. Poster presented at: The ARVO Annual Meeting; May 6, 2007; Fort Lauderdale, FL