Presbyopia-correcting IOLs (PC-IOLs) offer patients excellent options for range of vision compared to standard lenses. However, with these premium lenses come out-of-pocket costs — and higher expectations. Even with successful cataract surgery, a patient may return with complaints. It is crucial to understand and address these concerns to ensure patient satisfaction and optimize visual outcomes.

In this article, we’ll discuss the steps you can take to ensure a happy outcome for your patients.

TAKE A THOROUGH HISTORY

One of the biggest reasons we see unhappy patients for a second opinion is the feeling their surgeon or provider did not listen to their complaints.

It can be very difficult as a surgeon to listen to a patient complain after what seems likes an excellent outcome. It can also be easy to brush off their concerns because their vision is 20/20 and excellent at near as well.

To effectively address patient complaints, take a moment to listen to the patient discuss their challenges. Sometimes listening is the best way to make a patient feel comfortable with their outcomes. Then, start to ask specific questions to better pinpoint the challenges they are having. Is the challenge at distance or near? Does it occur during the day or at night? With blurry vision, does it affect one eye or both eyes? Complaints of positive dysphotopsias such as streaks of light, starbursts and halos should be elaborated on. Understanding these complaints will help guide you in work up and treatment.

End the conversation with a discussion about how you are going to work together to get better vision. This is whether it is your own surgery or a referred patient or second opinion. The patient may have complaints about the previous surgeon or practice, but redirect the patient to focus on the future and how you can treat their challenges.

Additionally, educate your co-managing doctors on what to listen for if you as a surgeon are not seeing the patient in the post-op visits.

PERFORM A COMPREHENSIVE EXAM

Various pathologies can contribute to post-surgical complaints. The cornea should be evaluated for postoperative changes such as haze, scarring or anterior basement membrane dystrophy (ABMD) as well other cornea changes. A dilated fundus exam along with optical coherence tomography (OCT) of the macula can detect conditions such as epiretinal membrane (ERM), vitreomacular traction (VMT) or cystoid macular edema (CME). These assessments should ideally be performed preoperatively as well to establish a baseline and identify any preexisting conditions that may contribute to post-surgical symptoms.

Careful preoperative and postoperative refraction is also important, since refractive error is the most common cause of unhappy patients.¹ Across several studies of all lenses, 55-80% of patients had postoperative outcomes within 0.5 D and 91-99% within 1.0 D of the intended target.^2-5 A contact lens can be trialed for treatment of refractive error. If the patient has improved symptoms, then a decision can be made for laser refractive surgery or lens-based surgery. When communicating with patients, it is important to warn of these potential refractive errors ahead of time and encourage patients to exercise patience during the initial months following surgery.

ADDRESS OCULAR SURFACE DISEASE

Ocular surface disease is a common component of visual disturbance and discomfort, with cataract surgery as a potential aggravator of dry eye disease (DED) symptoms.^6-7 Comprehensive workup with fluorescein/conjunctival staining, tear break-up time (TBUT) and a patient questionnaire is especially important since the prevalence of DED prior to cataract surgery is underreported.⁸ Corneal topography with Placido images can also be helpful for evaluation of surface irregularities, which can lead to inaccurate IOL measurements and axis calculations for toric IOL.⁹

Differentiating between aqueous-deficient and evaporative etiologies can help with addressing the underlying cause of dry eyes. For patients with postoperative ocular surface disease, it is best to be aggressive with treatment. Initial treatment options can include preservative-free tears, nighttime gels, low-dose topical steroids and immunomodulators. In addition, punctal plugs can help patients with aqueous deficiency, while tear stimulation can increase basal tear secretion.

BE WARY OF PCO

Posterior capsule opacification (PCO) is the most common postoperative complication, occurring months to years after cataract surgery. Some of the complaints of PCO — glare, nighttime driving issues, lack of visual clarity — overlap with complaints of PC-IOLs. Therefore, it is key to understand the timeline of symptoms. If the patient was seeing well after surgery but had worsening vision over time, then a PCO is likely and warrants treatment with laser capsulotomy. However, if the complaints started right after surgery, hold off on laser treatment and see if the symptoms improve. The possibility of an IOL exchange should delay laser treatment as a posterior capsulotomy will make the future procedure more difficult, particularly in terms of managing prolapsed vitreous at the time of exchange.

If you decide to treat, start with a small capsulotomy limited to the non-dilated visual axis. If the patient’s vision improves and can benefit from a larger capsulotomy, then a second laser treatment is always an option (but usually unnecessary). If the patient still has complaints, the small posterior capsule opening can be managed during lens exchange.

UNDERSTAND NEUROADAPTATION

The brain possesses an incredible ability to adapt, a quality that extends to visual adaptation as well. With multifocal lenses, the process of neuroadaptation plays a vital role. Our visual cortex is naturally accustomed to monofocal images from both eyes that combine to generate a binocular image necessary for depth perception. However, with multifocal lenses, the visual input consists of both focused and defocused images, requiring our visual cortex to change the way it interprets images. This adaptation necessitates the formation of new neural pathways which may take several months for full acclimation to occur. One study performed postoperative functional MRI in patients with multifocal IOL, demonstrating increased cortical activity with glare-inducing light stimulus.^10-11 This increased cortical activity, which likely represented the neuroadaptation process, lasted until 6 months at which complaints of dysphotopsias significantly decreased on symptom questionnaires.^10-11 Younger patients tend to have quicker neuroadaptive changes, although accurately predicting which individuals will be good candidates remains a challenge.

DECIDE TO TREAT

For unhappy patients, it’s important to offer a solution to their challenges once a sufficient workup is performed to exclude other causes. One example is expectation of the IOL platform. Extended depth of focus lenses, for example, may not provide as much near vision, which should be discussed in the pre-op visit. However, these patients may do well with just a reading glasses Rx or a contact lens trial to see if mini monovision with cornea refractive surgery would be better.

If the issue is a residual refractive error, then decide between laser refractive surgery and lens-based surgery. If the challenge is persistent photopsias, then an IOL exchange may be needed. While IOL exchanges are generally considered a safe procedure, it is important to warn patients that they carry higher risks compared to the initial cataract surgery. Any surgeon who places a premium lens should also have the skills to exchange a problematic lens.

In addition, the surgeon will need to decide which lens should be placed during the exchange. We lean towards a monofocal lens for most patients — if they failed neuroadaption the first time, we do not want to risk it again. Plus, the surgery may have been more than 6 months prior, in which case bag to bag IOL exchange may be challenging. It is also reasonable to exchange a trifocal for a less glare prone lens like an extended depth of focus lens. Companies may cover the cost of the lens if it is the same platform as the lens being removed.

SPECIAL CONSIDERATIONS

Due to the out-of-pocket expense to the patient for these lenses, the expectations are high. It is important to have a clear setup for how to address any post-op complaints. Some practices offer a package that includes any refractive procedures after for touch up. This may also include waiving the surgeon fee for a lens exchange. However, other practices do not include these post-op adjustments and instead will charge the patient more after or refer the patient. Either option needs to have careful documentation and communication about the plan especially the latter where patients may be upset about unexpected post-op charges.

CONCLUSION

Performing successful cataract surgery means ensuring a happy outcome for the patient. When faced with an unhappy patient after premium lens surgery, a thorough history, comprehensive exam, evaluation for PCO and understanding of neuroadaptation are all necessary steps. Most important of all, the patient should be offered a good explanation and solution to their challenges. By being patient with the workup and having an honest discussion with patients, optimal visual outcomes and patient satisfaction can be achieved with PC-IOLs. OM

REFERENCES

1. Abdelghany AA, Alio JL. Surgical options for correction of refractive error following cataract surgery. Eye Vis (Lond). 2014;1:2. Published 2014 Oct 16.
2. Lagrasta JM, Allemann N, Scapucin L, et al. Clinical results in phacoemulsification using the SRK/T formula. Arq Bras Oftalmol. 2009;72:189-193.
3. Aristodemou P, Knox Cartwright NE, Sparrow JM, Johnston RL. Formula choice: Hoffer Q, Holladay 1, or SRK/T and refractive outcomes in 8108 eyes after cataract surgery with biometry by partial coherence interferometry. J Cataract Refract Surg. 2011;37:63-71.
4. Cooke DL, Cooke TL. Comparison of 9 intraocular lens power calculation formulas. J Cataract Refract Surg. 2016;42:1157-1164.
5. Kane JX, Van Heerden A, Atik A, Petsoglou C. Accuracy of 3 new methods for intraocular lens power selection. J Cataract Refract Surg. 2017;43(3):333-339.
6. Venkateswaran N, Luna RD, Gupta PK. Ocular surface optimization before cataract surgery. Saudi J Ophthalmol. 2022;36):142-148. Published 2022 Aug 29.
7. Trattler WB, Majmudar PA, Donnenfeld ED, McDonald MB, Stonecipher KG, Goldberg DF. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430. Published 2017 Aug 7.
8. Cho YK, Kim MS. Dry eye after cataract surgery and associated intraoperative risk factors. Korean J Ophthalmol. 2009;23:65-73.
9. Han KE, Yoon SC, Ahn JM, et al. Evaluation of dry eye and meibomian gland dysfunction after cataract surgery. Am J Ophthalmol. 2014;157:1144-1150.e1.
10. Rosa AM, Miranda ÂC, Patrício M, et al. Functional magnetic resonance imaging to assess the neurobehavioral impact of dysphotopsia with multifocal intraocular lenses. Ophthalmology. 2017;124:1280-1289.
11. Rosa AM, Miranda ÂC, Patrício MM, et al. Functional magnetic resonance imaging to assess neuroadaptation to multifocal intraocular lenses. J Cataract Refract Surg. 2017;43:1287-1296.

William Xu is a medical student at Baylor College of Medicine in Houston and is applying to ophthalmology residency in the fall.

Sumitra S. Khandelwal, MD, is an associate professor at Baylor College of Medicine in Houston.