Patient dissatisfaction most common cause for multifocal lens explantations

September 14, 2008

Preop chair time is vital for multifocal patients to correctly evaluate motivation and manage expectations correctly, Dr Jorge Alio told delegates during a presentation on how to rescue an unhappy multifocal patient.

Preop chair time is vital for multifocal patients to correctly evaluate motivation and manage expectations correctly, Dr Jorge Alio told delegates during a presentation on how to rescue an unhappy multifocal patient.

Dr Alio also revealed that neural-processing training could improve the contrast sensitivity function of an unhappy patient.

He opened his talk with an unusual case, a patient with a UCVA of 20/20 and UCNVA of J1 postoperatively. It made for a happy surgeon.

"But the patient was unhappy. The patient complained of day and night glare, phantom images, he reported a reduction in vision quality and contrast, but there was no evident disability in the patient's quality of life, " Dr Alio noted. This led to a stressed surgeon, Dr Alio quipped.

The evolution of the problem included a lot of chair time with the patient, but no improvement. The patient had a Type B personality, which led to a lot of confusion and misunderstandings.

Ultimately, this case led to explantation and monovision. Dr Alio noted that debilitating glare led to 4.5% to 8.5% of multifocal IOL explantation. Severe halos caused 16%, and the problems were greater in clear lens extraction cases. Personally, Dr Alio explanted 8 to 10%. "Multifocal IOL dissatisfaction is the most frequent reason for explantation in my practice, " he noted.

Reasons for unhappiness included residual refractive error, especially astigmatism. Low contrast sensitivity and 'insufficient' visual acuity join halos, glare and unrealistic expectations as common causes of complaint.

For halos and glare, Dr Alio recommends waiting. "They decrease with time, in many cases, " he said. Chair time is also important, and the surgeon should correct any residual refractive error.

Low contrast sensitivity is reported by patients as 'insufficient' visual acuity, and is caused by the dispersion of light in different foci, leading to a degraded image. It is very negatively affected by residual PCO, but can improve in time to normal levels. Again chair time, correction of residual errors, improved reading light and Yag capsulotomy where indicated.

If the patient is not reaching 20/20, macular oedema or macular degeneration may be to blame, as may PCO. Dr Alio recommends that surgeons test macular function with the potential visual acuity test and to use OCT to test macular anatomy.

Unrealistic expectations are very hard to deal with if inadequate chair time is devoted to the patient preoperatively. Postoperative chair time is not as effective. "It is perceived as a method to justify a poor outcome, " Dr Alio warned.

Neurovision training may also be a solution if the image is blurred, vision remains unimproved by spectacle correction and there is insufficient improvement with time. "It is usually associated with disabling glare, " Dr Alio revealed.

He said that neural plasticity meant it was possible for the brain to adapt and that this adaptation can be trained using computer-based visual training with tilted bars.

He told delegates that orientation VA can be improved significantly and that orientation discrimination learning influenced particularly contrast sensitivity and near vision contrast. The training effect lasted over six months and the training effect was after the first three sessions.

In conclusion, Dr Alio said that adequate clinical evaluation of residual refraction, the macula, PCO and IOL optical performance were essential in dealing with an unhappy patient.

Waiting time and chair time were both very important and in neuroprocessing training for contrast sensitivity function is an option. But, ultimately, explanation may be needed in some cases.

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