Bring the unhappy IOL patient back from the brink

How to get VA back on track despite unrealistic patient expectations.

By David A. Goldman MD

About the Author
	David Goldman, MD, is founder of Goldman Eye in Palm Beach Gardens, Fla. Disclosure: Dr. Goldman had no relevant conflicts to disclose.

While many explanations for patient dissatisfaction after having a refractive IOL implanted exist, in 90% or more of these cases I have found the patients had unrealistic expectations. Although we go to great lengths to explain the limitations of current IOL technology, and the patient may even sign a consent, this does not necessarily mean the patient does indeed understand.

Many times after patients say they want to depend less on spectacles, they drift off, imagining superhuman-like vision. Industry-sponsored literature may also falsely elevate patient expectations. So it is important we tell any patient about to undergo cataract surgery with an IOL what to realistically expect on two separate occasions.

If the patient has a risk factor that may limit outcomes, such as pseudoexfoliation syndrome, we should fully educate her or him about the condition. We should try to under-promise and over deliver. In some cases, organic causes may limit success of the refractive IOL. This article focuses on treatments for those situations.

ACCOMMODATING IOLS

A larger capsulorhexis

For accommodating IOLs, patient complaints may include limited reading ability or Z syndrome, or both. Fortunately, the latter has become almost nonexistent with the newer generation lenses. However, we should always be suspicious in a case of increasing astigmatism that does not correlate with topography.

To minimize this risk, I prefer making the capsulorhexis approximately 5.5 mm to 6 mm in size, and I confirm both haptics are within the capsular bag. If a Z syndrome occurs in spite of this, careful YAG laser extending the capsulotomy under the haptic-optic junction can restore a planar position.

In cases of limited reading ability, a cycloplegic refraction is indicated. Often, these patients are mildly hyperopic and are using their accommodative ability to reach plano. Piggyback lenses or laser vision correction can cure these cases. Many surgeons will target some myopia in the non-dominant eye to expand the range of uncorrected vision.

MULTIFOCAL IOLS

The ‘Six C’s’ of patient complaints

Complaints from patients unhappy with multifocal IOLs tend to focus on glare/haloes and/or “Vaseline vision”. In these cases, we should check several items. Eric Donnenfeld, MD, described them as the “Six C’s”:

• Cylinder. For multifocal IOLs to function properly, the optical system must be perfect. Residual astigmatism can decrease their performance greatly. Laser vision correction can always be effective. However, if the spherical equivalent of the refractive error is plano, then limbal relaxing incisions may be indicated. An excellent free resource can be found at www.lricalculator.com.

• Cornea. Tear film can be the most important refractive part of the eye, and instability diminishes performance of a multifocal lens. In fact, reports have shown that patients without dry eyes placed on cyclosporine two weeks preoperatively and for three months postoperatively had better vision and more ocular comfort.^1,2

• Capsule. Posterior capsule opacification can be disabling in even mild forms with a multifocal IOL. We should be certain the PCO is significant, because if you’re considering an IOL exchange, an open capsule will make it more challenging.

• CME. Cystoid macular edema may not be clinically evident, so I suggest performing macular OCT on any dissatisfied multifocal IOL patient. A patient with 20/20 uncorrected vision can quite possibly have CME. Topical steroids and NSAIDs may be indicated, but long-standing cases of CME may require intravitreal therapy.

• Centration. “Vaseline vision” after cataract surgery with a multifocal IOL often results from a large angle kappa, even when the lens is well centered within the capsular bag. Intraoperative centration is critical, although postoperative intervention is a possibility. Laser iridoplasty to re-center the pupil has been shown to improve visual acuity, but this is only an option in mild cases of decentration.

• Crazy. Whether the patient has supratentorial issues or the physician was crazy to think she or he was a suitable candidate, multifocal IOLs are not for everybody. When nothing appears to satisfy the patient, offer lens-exchange surgery. Monofocal vision may not ameliorate all symptoms, but the patient will no longer feel the IOL is to blame.

Ultimately, not all patients who receive accommodating or multifocal IOLs 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 a second opinion before any intervention. OM

REFERENCES

1. 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.

2. Donnenfeld ED, Perry HD, Wittpen J Jr, et al. Cyclosporine on quality of vision in patients undergoing IOL implantation. Poster presented at: ARVO Annual Meeting; May 6, 2007; Fort Lauderdale, FL.