Managing the dissatisfied multifocal IOL patient

Houston-Implant exchange in multifocal IOL recipients unhappy with their vision is better performed sooner rather than later. It is even better to avoid the exchange whenever possible by identifying and addressing a treatable cause for the patient’s complaints.

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The best strategy of all is to prevent dissatisfaction in the first place by attention to patient selection and preoperative management, said Stephen G. Slade, MD.

“Some patients will never be satisfied with a multifocal IOL because of their visual needs or ocular comorbidities,” said Dr. Slade, private practice, Slade and Baker Vision, Houston.

“Therefore, it is important to determine a patient’s suitability preoperatively by taking a careful history and performing a comprehensive examination.

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“Thorough history and examination are also important when a patient presents with complaints after surgery to help the surgeon understand the nature of the problem and its possible cause,”

 he continued.

Dr. Slade also noted that surgeons might see multifocal IOL patients on referral that clearly should undergo IOL exchange.

“Someone who had extensive radial keratotomy in the past, whose lens is decentered, or who has a retinal condition that interferes with the optics of the multifocal, may likely never be happy and should have the IOL adjusted, if appropriate, or removed,” Dr. Slade said.

Obtaining a detailed explanation of the patient’s symptoms-e.g., is there blurred vision and at all distances or dysphotopsias-and when the problem(s) began may provide clues to their etiology. The list of treatable causes includes residual astigmatism, ocular surface issues, and posterior capsule opacification (PCO).

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“Hitting the refractive target is important for good vision with a multifocal IOL, and multifocal IOLs are particularly sensitive to residual refractive error,” Dr. Slade said.

However, in choosing a method to correct any refractive error, Dr. Slade advised against PRK.

“Return to good vision takes a longer time after PRK than LASIK, and especially in a patient with a multifocal IOL,” he explained. “The irregularity of the healing epithelium can interfere with a multifocal optic, and it can take months before patients are happy with their vision.”

Patients should also be evaluated for dry eye disease as a treatable cause for poor vision, and the posterior capsule should be examined for opacification.

However, since IOL exchange becomes more difficult after Nd:YAG capsulotomy, surgeons should be convinced that PCO explains the patient’s complaints before opening the capsule. Then, Dr. Slade advised erring on the side of caution by doing just a small capsulotomy at first to see if there is any improvement.

NEXT: Conclusion

He illustrated this approach with a case presentation involving a 56-year-old woman. She had a small amount of residual astigmatism, but stated she was also unhappy with her vision while wearing her glasses. The examination revealed a hazy capsule with extensive lens epithelial cells. The patient was unable to recall if she was ever happy with her vision after surgery, making it more difficult to determine if PCO was the underlying cause.

Proceeding conservatively, Dr. Slade vacuumed the cells off the capsule. Afterward, the patient reported her vision quality was much better and blurriness had disappeared, and she was scheduled for Nd:YAG capsulotomy.

Stephen G. Slade, MD

E: [email protected]

Dr. Slade is a consultant to Alcon Laboratories, Bausch + Lomb, and ReVision Optics.