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Panel discusses patient who has poor visual quality after cataract surgery
The patient’s family history of glaucoma also contributed to his problems.
 Eric D. Donnenfeld |
Eric D. Donnenfeld, MD, FACS: This is a patient who had a history of high myopia, –10 D to –12 D, thick corneas, normal keratometry. He told me that he had cataract surgery done and he had Alcon ReSTOR multifocal IOLs placed in the bag in both eyes. But he was complaining of tremendous glare, halo and decreased visual acuity, and he was unhappy with his quality of vision. He came to me for a second opinion.
I refracted him, which is the first step when any patient is unhappy with cataract surgery or, particularly, with refractive IOL technology. Indeed, the patient’s best corrected visual acuity was 20/30 in the right eye and 20/40 in the left eye, so there was an issue that went beyond refractive error.
 Kerry D. Solomon |
When you look at this image of the patient (Figure 1), you see two different haptics. You see an acrylic haptic and a Prolene haptic, and we documented, by doing Visante OCT, that there were two IOLs sitting in the bag. In questioning the original surgeon later, we found out that the IOL did not come in the desired power so he used a piggyback lens in the bag to resolve the residual refractive error. The patient also turned out to have a family history of glaucoma and had significant cupping with inferior nerve fiber layer thinning and actual visual field loss. So this patient had some glaucoma issues in addition to this problem. We did topography in the patient. Dr. Solomon, when you see topography like this, what are your thoughts (Figure 2)?
Kerry D. Solomon, MD: When I look at that topography, you have some irregular astigmatism that seems to be present in both eyes. This could be pre-existing irregular astigmatism, but to me, this looks like dry eye.
When you said the patient did not improve with refraction, I think you need to go beyond just refraction. I would do a wavefront on him and see if there is any higher-order aberration. Samuel Masket, MD, was one of the first to say and to really find that until we can get our patients truly to plano, any of the multifocal patients are going to notice some aberrations. And a good test for any of these little micro-irregularities would be a soft or a hard contact lens over refraction. In this case, if a hard contact lens over refraction tuned up the patient, you would know it is surface-related. Look for some irregular astigmatism. In this case, I would bet this is dry eye, and I would treat aggressively for dry eye management.
 Two different haptics are shown in the eye.  Topography of a patient complaining of glare, halo and decreased visual acuity. Images: Ophthalmic Consultants of Long Island |
Dr. Donnenfeld: Dr. Solomon hit the nail on the head. Clearly this patient had dry eye, and there are some easy things you can do. You can put a teardrop in the patient’s eye, and if the patient says, “My vision just got a lot better immediately,” or they say their vision is fluctuating, visual fluctuation is almost a pathognomonic sign of ocular surface disease. So remember that the next time a patient walks into your office and says, “My vision changes between blinks. My vision is better in the morning than it is at night.” Unless they had radial keratometry and their eyes are changing shape during the day, it is almost always going to be ocular surface disease. Also, there are areas of dropout on the topography due to poor Placido disc image. Any time you see dropout on topography, think ocular surface disease.
For me, quality of vision all starts with tear film, so any type of surgery we do, whether it be LASIK or PRK, cataract surgery or multifocal IOL implantation, if a tear film is not functioning well, the patient will not see well. So that is my first step in managing patients.
Dr. Solomon: And if you see this preoperatively, you need to fix this before they go on to surgery, whether it is cataract, LASIK, PRK or otherwise.
 Marguerite B. McDonald |
Dr. Donnenfeld: And I think that is something that a lot of ophthalmologists may not pay enough attention. I do a dry eye work-up on any patient coming to me for any surgical procedure, no matter what it is — corneal transplant, glaucoma, filtering surgery and certainly refractive surgery. So what can be done to improve the ocular surface in this patient?
Marguerite B. McDonald, MD: I would put this patient on unpreserved or artificial tears, or a very mildly preserved tear, transiently preserved, every 1 to 2 hours while awake for the full-court press. I would put them on cyclosporine emulsion twice a day. I would give them bland ointment at night, nutritional supplements, and say, “See you in 1 month.” If in 1 month they were improved but not perfect, I would put in lower plugs and see them 1 month later. If they are improved but still not perfect, I would put in upper plugs.
Dr. Donnenfeld: I agree with everything that Dr. McDonald just said. Drops, transiently preserved, and ointments at night. Look for lid positioning as well. You want to make sure that there are no entropia and ectropia and other issues. But is there anything that can work a little faster?
 Charles B. Slonim |
Charles B. Slonim, MD, FACS: I agree with the treatments mentioned so far. However, I probably would not plug them right away. I would go ahead and start them on Lotemax (loteprednol etabonate 0.5%, Bausch & Lomb). You are going to get your biggest bang for your buck right there. It is going to take a while for the cyclosporine to take effect, so I would put them on four times a day for a couple of weeks and then twice daily for another month to 6 weeks or beyond while at the same time starting Restasis (topical cyclosporine A 0.05%, Allergan) 2 weeks later.
Dr. Donnenfeld: As Dr. McDonald said, wait about 1 month and then plug them if need be, after you have done all these things.
Those are all wonderful management options for a patient like this. We did all those things. We put the patient on cyclosporine, loteprednol, tears and oral nutritional supplements.
For more information:
- Eric D. Donnenfeld, MD, FACS, can be reached at OCLI, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com.
- Marguerite B. McDonald, MD, can be reached at OCLI, 266 Merrick Road, Lynbrook, NY 11563; 516-593-7709; fax: 504-232-3641; e-mail: margueritemcdmd@aol.com.
- Charles B. Slonim, MD, FACS, can be reached at Older and Slonim Eyelid Institute, 4444 East Fletcher, Suite D, Tampa, FL 33613; 813-971-3846; fax: 813-977-2611; e-mail: slonim@eyelids.net.
- Kerry D. Solomon, MD, can be reached at Medical University of South Carolina, Storm Eye Institute, 167 Ashley Ave., Room 221, P.O. Box 250676, Charleston, SC 29425; 843-792-8854; fax: 843-792-6347; e-mail: solomonk@musc.edu.