Address refractive error, dryness before labeling patients as ‘visually demanding’
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When working with patients who are dissatisfied with their multifocal IOLs after cataract surgery, there are several factors to address before assuming the patient is visually demanding, according to a speaker.
“If I had cataract surgery with a multifocal IOL and spent a lot of money on it, I would have high expectations, too,” John P. Berdahl, MD, said at the virtual Real World Ophthalmology meeting. “And our job is to deliver on those expectations.”
The first problem Berdahl addresses is dryness.
“This is the second most common problem — it’s the problem that you treat first,” Berdahl said. Lubrications, medications, thermal pulsation, modifications, punctal plugs and omega-3 supplements may be useful, but dryness is challenging for many patients.
“The refractive error is the most common problem,” Berdahl said. “By treating the refractive error, most patients will be really happy.”
To make sure a refractive error is the true culprit, Berdahl said he will prescribe an inexpensive pair of glasses.
“If a patient puts those glasses on, do they love it? If so, then we know that it’s a refractive error, and we are ultimately going to go on to an excimer enhancement. If not, there is something else going on. We are not going to YAG that patient. We’re not going to do LASIK on them until we know what else it might be,” he said.
“It’s also important to know if positive dysphotopsias were the issue from the lens itself, not from the PCO, before you do the capsulotomy,” Berdahl said. “Patients that have multifocal IOLs will have some rings, some glare and some halos, but it doesn’t bother the vast majority of patients.”
If posterior capsule opacification (PCO) is the problem, it is easily treatable with YAG laser, Berdahl said. “But you only want to do it if you know that that’s the problem.”
Finally, a problematic near point could cause unhappiness, Berdahl said. The issue has become less problematic with the use of trifocal IOLs.
“If you are using bifocal multifocals that have a distance vision and either a near point at intermediate or distance, there is usually a no-man’s land, depending on where that near point is,” he said.
Before deciding a patient is “visually demanding,” Berdahl suggested treating every other possibility first.
“Show them a pair of –3 glasses and put a pair of –3 loose lenses in front of them and show them what their near vision would be like if they didn’t get this lens. It is really helpful for them to see what they are actually getting,” Berdahl said.
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Berdahl J. Managing unhappy multifocal patient. Presented at: Real World Ophthalmology; Sept. 18, 2021 (virtual meeting).
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