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An algorithmic approach to problem solving for patients who are dissatisfied after implantation of presbyopia-correcting IOLs aims to streamline identification of the etiology of the visual complaints and implementation of a successful solution, said Parag Majmudar, MD.
Chicago-An algorithmic approach to problem solving for patients who are dissatisfied after implantation of presbyopia-correcting IOLs aims to streamline identification of the etiology of the visual complaints and implementation of a successful solution, said Parag Majmudar, MD.
“Be sure to underpromise when discussing outcomes with patients who will be receiving presbyopia-correcting IOLs, but even then, you may be faced with situations where you have not ‘over-delivered,’ ” said Dr. Majmudar, associate professor of ophthalmology, Rush Medical College, Chicago.
Waiting a minimum of 2 weeks between fellow eye surgeries is helpful because assessment of the first outcome can help guide decisions for achieving satisfaction after binocular surgery. Always listen carefully to patient complaints, convey sincere concern, and work actively to figure out the underlying cause, letting patients know you are their partner, he added.
“Consider all possible causes and options for correction, but always keep in mind that Nd:YAG capsulotomy to treat posterior capsule opacification (PCO) is best avoided if there is any possibility for needing IOL exchange because opening the capsule will magnify the potential for complications with IOL exchange,” Dr. Majmudar said.
When multiple possible etiologies exist for patient dissatisfaction, an algorithmic approach may allow for a more systematic evaluation.
“I first heard Roger Steinert, MD, propose an algorithmic strategy to sorting out the problems that can plague patients after implantation of presbyopia-correcting IOLs,” Dr. Majmudar said, “I believe that this common-sense approach may pinpoint the specific cause expeditiously.”
Trouble with near vision but without complaints about distance or intermediate function is one scenario that may be encountered after multifocal IOL implantation, particularly with some of the earlier-generation multifocal or pseudo-accommodating lenses.
Recommending spectacle wear as needed is one option, and some patients may accept wearing glasses for specific tasks. Patients whose complaints indicate their near vision problems are limited to dim lighting conditions can be advised to improve task lighting, including by carrying a penlight. Pharmacologic intervention using brimonidine tartrate (Alphagan P, Allergan) or a low concentration of pilocarpine (0.5%) to induce miosis may also be considered, particularly for younger patients who tend to have larger pupils.
Complaints about intermediate vision were more of an issue in patients with the +4 D version of the apodized diffractive MFIOL (AcrySof IQ ReSTOR SN6AD3, Alcon Laboratories) implanted and are less common with the newer +3 D technology (SN6AD1, Alcon). Again, recommending glasses for specific tasks, such as working at the computer, is a possible solution, but one that may not be acceptable to the patient, particularly if the surgeon overpromised about postoperative spectacle independence.
“In the preoperative consultation, keep in mind that we now have a range of presbyopia-correcting implants available that vary with respect to visual performance at different distances,” said Dr. Majmudar, who is also partner and chief medical officer, Chicago Cornea Consultants. “Identifying the patient’s functional needs and matching them to an appropriate IOL will help to minimize postoperative dissatisfaction.”
There are multiple possible causes to consider if the patient is complaining about poor vision at both distance and near. Ocular surface irregularity is a common finding in patients who have undergone surgery, and patients should be evaluated and treated as necessary for meibomian gland dysfunction and dry eye disease. As usual, preoperative identification and pre-treatment is best, but for postoperative management, Dr. Majmudar noted he has increased his use of autologous serum drops in patients with advanced dry eye disease.
Corneal disease may also account for poor near and distance vision, and Dr. Majmudar reminded surgeons about the importance of careful preoperative evaluation to assess corneal clarity and presence of guttae to guide proper patient selection. Investigation of a corneal cause for poor vision postoperatively should include topography as well as use of hard contact lens overrefraction as necessary, he said.
Poor vision at near and distance may also originate from disease of the macula or optic nerve. Optical coherence tomography is one way to identify these issues, but the Amsler grid offers a simple and inexpensive way to detect some hidden posterior segment pathology.
Suboptimal IOL centration should also be considered in patients complaining about poor near and distance vision, especially in those with a diffractive multifocal IOL implanted. Dr. Majmudar noted that Eric Donnenfeld, MD, has reported success performing argon laser annular or sectoral iridoplasty to cause contraction and retraction of the iris tissue focally, and thereby re-center the pupil over the IOL. The procedure is performed using a spot size of 500 µm, pulse duration of 500 milliseconds, and power of 500 mW.
“If none of these problems is identified, consider IOL exchange, but first evaluate the posterior capsule for opacification under dilation using retroillumination,” Dr. Majmudar said. “Don’t forget that when there is early opacification, distance acuity may be relatively good while near vision may be compromised to a greater degree. But always be careful about performing Nd:YAG laser capsulotomy if IOL exchange is being considered, because the risks of IOL exchange increase dramatically when the posterior capsule has been opened.”
When patients have relatively good acuity at all distances but complain about halos and glare, it is important to evaluate each eye separately by having the patient cover one eye at a time to determine whether one eye or both is involved. Asking the patient to draw the visual disturbance can also provide helpful insight about the cause.
Abnormalities of pupil size and shape may be a possible underlying cause for complaints of halo and glare that can be addressed using pharmacologic intervention with 0.5% pilocarpine or brimonidine or by performing argon laser iridoplasty. PCO may also lead to dysphotopsias, but again, surgeons should proceed cautiously in performing capsulotomy until after ruling out other etiologies.
“Problems with halos and glare are most often due to refractive issues, such as uncorrected or induced astigmatism, or perhaps corneal aberrations arising from epithelial membrane dystrophy, and consideration should be given to addressing these findings either with excimer laser vision correction or with spectacles prior to undertaking IOL exchange,” Dr. Majmudar concluded.
Dr. Majmudar has no financial interest in the subject matter.
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