How do you deal with neuroadaptation problems with a presbyopia-correcting lens?
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Wait and watch
When I see patients experiencing problems with a premium presbyopia-correcting IOL, I first and foremost always wait because I need to figure out the root cause as to why they are unhappy.
The two main reasons are undiagnosed ocular surface disease or residual refractive error, both of which need further investigation using a stepwise approach. If I suspect undiagnosed ocular surface disease, I immediately check the ocular surface, perform fluorescein staining as well as point-of-care testing to detect surface inflammation or increased tear osmolarity, and treat them to rule out dry eye as a reason why they may be struggling with their vision. If the potential cause is residual refractive error, I investigate this by performing corneal diagnostic imaging and a refraction. I then always perform a glasses or contact lens trial. If patients experience a significant improvement in their quality of vision with a trial and the degree of correction is small, a laser vision enhancement can be considered; larger refractive errors may require an IOL exchange or a piggyback lens. However, I have to prove to myself and the patient that the refraction is stable, and this requires at least 1 month, if not 3 to 6 months. Time, again, is on our side, and in quite a few cases, patients will end up choosing no intervention or a conservative therapy rather than undergo a secondary surgery. Bothersome glare and halos that occur after surgery with multifocal IOLs can be mitigated by drops that constrict the pupil. Symptoms may or may not resolve, but time is required for the drops to take effect or for the patient to neuroadapt.
Ultimately, time is our best ally with premium IOL patients. We will always have some challenging patients, but if we take the time to hold their hands and counsel them on common causes of blurred vision with multifocal IOLs, we can usually make them happy or overall more satisfied. I would only consider expedient surgery in a minority of cases, ie, a tilted or decentered IOL, a rotated toric IOL or in cases in which there was a significant refractive miss. However, for the majority of patients, I would urge surgeons to consider waiting and watching. Oftentimes, performing surgery sooner on the fellow eye can be advantageous and help with binocular neuroadaptation with multifocal IOLs.
Nandini Venkateswaran, MD, is from Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston.
Do not wait too long to intervene
When we see patients who report significant dissatisfaction with their vision after implantation of a presbyopia-correcting IOL, we tend to forget how difficult it might be for them to get through the day.
We typically measure vision in the office with high-contrast Snellen acuity, and patients might be able to read 20/25 or 20/20, but what they experience in their everyday life might be quite different. Waxy or poor-quality vision and photic phenomena, such as rings of light, spiderwebs and starbursts, are common descriptors used by patients, and we may overlook how frustrated they might be at home, not being able to see in dim light conditions, to drive at night or to tolerate being outside at night. Think of a patient who has to commute by car every day from work in the winter when it is dark. It is true that it is important to wait and see if explanting a lens is necessary, but I think we should not wait too long before we alleviate the mental stress of these patients and allow them to get back to normal life.
Importantly, we must consider that the longer we wait, the more challenging IOL exchange can be. Anterior capsular phimosis can be robust and make safe IOL dissection and removal difficult. If the lens is significantly scarred into the bag, there is a higher risk for zonular dehiscence, damage to the capsule and need for vitrectomy with removal, making secondary lens implantation problematic and increasing the risk for retinal complications.
With patients who complain of poor near acuity, I tend to wait a little longer for exchange because this can improve with adaptation and occasional use of reading glasses. For patients with severe dysphotopsias or photic phenomena that do not improve within 6 to 8 weeks, I think that early exchange should be considered.
Kourtney H. Houser, MD, is from Duke University School of Medicine, Durham, North Carolina.
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