Careful investigation using a systematic approach to troubleshoot patients dissatisfied after multifocal IOL implantation usually can identify an underlying cause that can be effectively managed with conservative intervention and avoidance of further intraocular surgery.
"Multifocal IOL optics are imperfect and do not function well in persons with any abnormalities of the visual system," said Dr. Stulting, director, Stulting Research Center, Woolfson Eye Institute, Atlanta. "Careful preoperative evaluation is critical for avoiding problems after the procedure, but surgeons should also beware of patients with uncompromising personalities or insufficient motivation to avoid glasses.
"When [patients with multifocal IOLs] complain postoperatively about visual acuity or quality, methodical evaluation to identify an underlying cause will help to assure you've done everything possible to avoid intraocular surgery," he said.
Results of a published paper by Dr. Stulting and colleagues [J Cataract Refract Surg. 2009;35:992-997] reviewing the complaints, management, and outcomes in a series of patients dissatisfied after multifocal IOL implantation provide lessons on handling these problems.
A total of 44 consecutive patients were identified who were unhappy with their visual outcomes. After excluding 12 patients who had inadequate follow-up, data were summarized for 43 eyes of 32 patients with a refractive or diffractive multifocal IOL implanted. Nearly all patients (95%) complained about blurred vision, 42% experienced photic phenomena, and 37% reported both problems.
Data on etiology of visual complaints showed posterior capsule opacification (PCO) accounted for the majority of cases of blurred vision (54%) and photic phenomena (67%). Ametropia was responsible for almost one-third of the cases of blurred vision, while tear deficiency was not uncommon, and the etiology was often multifactorial.
Nd:YAG laser capsulotomy was performed in 15 (35%) eyes. Other interventions included spectacle wear, refractive surgery, treatment of dry eye, mydriatic treatment, argon iridoplasty, and lens repositioning or exchange.
Dr. Stulting and colleagues developed a management algorithm for evaluating and treating patients with multifocal IOLs and complaints of ametropia or photic phenomena.
When it comes to blurred vision, ametropia is the low-hanging fruit, he said.
"Multifocal IOLs are very sensitive to minimal refractive error," said Dr. Stulting, professor of ophthalmology, emeritus, Emory University, Atlanta. "We train our technicians to [perform refraction for] patients complaining of blurred vision, and if the symptoms are resolved, we offer corneal refractive surgery to achieve freedom from spectacle wear."
In performing the refraction, the technicians are also trained to try to duplicate the circumstances causing visual distress the patient. If the patient notes the difficulty occurs in a dim light situation, the refraction is performed with the room lights turned down, and if it is an issue in sunlight, then the patient may be taken outside.
IOL decentration is another possible cause of blurred vision, with possible solutions that include argon laser pupilloplasty, surgical repositioning of the IOL, or IOL exchange.