Address dysphotopsia in patients dissatisfied with cataract surgery
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NEW YORK — If patients are unhappy after their cataract surgery, surgeons need to know how to respond and how to remedy the common causes of dissatisfaction, according to a presentation at OSN New York.
One of the most common causes of patient complaints is pseudophakic dysphotopsia, comprising diffractive, negative and positive dysphotopsias.
“We try in the beginning to manage expectations,” Nicole R. Fram, MD, said. “We look at their personality type, we look at night driving checklists, we show simulations, but sometimes we’re just wrong. And so, the first step is to establish the history.”
Fram said this includes determining when the patient became unhappy — right after surgery or later — and why.
In diffractive dysphotopsia, Fram said she uses bimanual viscodissection and a Donnenfeld femto spatula to remove the lens.
“You can use 22-gauge forceps here to get your countertraction, but just make sure these AcrySof lenses (Alcon) are not going to get hung up at the terminal bulb,” she said. “You want to lift up before you start rotating so you don’t cause a zonulopathy, and by lifting up you can just go ahead and release that.”
She said that she prefers cutting the lens in half rather than folding it because it gives her more control.
“I find using a low index of refraction IOL, like LI61AO (Bausch + Lomb), is a dysphotopsia killer, and so this is my go-to,” Fram said. “For diffractive, you can put any amount of focal IOL in, but for positive [dysphotopsia], I like LI61AO.”
If a patient complains about flickering or fluttering off to the side, Fram said this could indicate negative dysphotopsia and should not be ignored.
“Ask if it’s coming and going,” she said. “This hasn’t been published, but this is my experience, that if it’s coming and going, it will likely go away.”
Secondary reverse optic capture is the best option for negative dysphotopsia, Fram said. It requires an anterior capsule opening of 5 mm to 4.8 mm, haptics at 6 o’clock and 12 o’clock, and the optic overlapping the nasal and temporal capsule, she said.
“If they have a lot of anisometropia and they have negative dysphotopsia in one eye, you can put a three-piece IOL in the [capsular] bag and then prolapse the optic anterior to the capsule while you’re waiting to figure out what you’re going to do with the other eye,” Fram said.
Fram said the surgeon should assure the patient that the problem can be resolved and that they will work together to find a solution.
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Fram NR. My patient is unhappy in the first eye ... what should I do? Presented at: OSN New York and OSN New York Retina; Oct. 15-17, 2021; New York.
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