Q&A: Five C’s help prevent, manage cataract surgery complications
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Cataract surgery is one of the most commonly performed procedures worldwide.
Technological advances for preoperative assessment, IOL power calculation and surgical precision have increased safety and predictability, and the market offers a wide range of IOL options to satisfy patients’ needs. Nevertheless, unforeseen complications may occur, and some patients may be dissatisfied with their outcomes.
Healio/OSN spoke with Eric D. Donnenfeld, MD, a cataract surgeon with decades of experience, to find out how to prevent the most common complications and deal with dissatisfied patients.
Healio/OSN: How do you deal with unhappy patients after cataract surgery?
Donnenfeld: With every patient who is unhappy after cataract surgery, I start by looking at the five C’s: corneal tear film, capsule, cylinder refractive error, cystoid macular edema and centration of the IOL. In my experience, by far the two most common reasons why patients are unhappy are residual astigmatism and ocular surface disease.
I have a simple testing sequence that my staff completes before I even see patients to try and elucidate the reasons for dissatisfaction. That entails refraction, topography and OCT of the macula, and those three tests alone will capture 95% of the unhappy patients. The only thing I have to do afterward is look at the cornea — issues sometimes will show up on the topography — and look at the capsule to see if it is opacified. So, those simple tests and a 30-second examination in most cases allow me to determine why the patient is dissatisfied.
Healio/OSN: What is your basic strategy to prevent postoperative issues?
Donnenfeld: The most important step I take is to maximize the ocular surface before surgery. The optical quality of the tear film is crucial for the quality of vision, and an improved tear film will also allow me to do a better evaluation of the keratometry, leading to better IOL calculation. A number of studies have shown that when you improve the ocular surface, your biometry and keratometry become more precise, and there is a greater likelihood that you are going to choose the right IOL and the right amount of cylinder correction. In addition, I recommend using a modern IOL calculation formula. The simple act of moving from an SRK/T to a Barrett or Hill-RBF formula results in 10% more of your patients achieving a plano postoperative refraction. Last but not least, I routinely perform OCT on all of my patients because it allows me to make an intelligent decision on what IOL to place. If I see cystoid macular edema or an epiretinal membrane, this drives me to a more conservative IOL choice.
Healio/OSN: How do you inform patients about potential issues following surgery?
Donnenfeld: One of the basic aspects of postoperative satisfaction is having the patient educated and informed preoperatively about the risks and benefits of the surgery. An informed consent is crucial, and I am clear with all my patients that there is a 10% to 20% chance that they may not be happy with their outcome and that additional enhancements may be needed, but postoperatively, we will work together to resolve any residual issues. I make it clear that cataract surgery is just the first step in their journey toward improved postoperative visual acuity and that we will work together to resolve any issues. If we tell patients that this is part of the process, they are not disappointed when they come back for enhancement postoperatively. Bear in mind that when you explain something to your patients preoperatively, it is an expectation. When you tell them postoperatively about problems they were not aware of, it is your complication.
Healio/OSN: What are your criteria for choosing an IOL that minimizes the risk of complaints?
Donnenfeld: You and the patient have to work together to decide what is the best option. Patients who have certain pathologies are generally not good candidates for diffractive multifocal IOLs. Monofocal and extended depth of focus (EDOF) lenses are a better alternative for these patients. They do not provide much reading vision, but they do not degrade visual acuity and image quality. I find that many patients are happy with mini-monovision, aiming for plano in the dominant eye and –0.75 D to –1.25 D in the nondominant eye, with an EDOF lens such as the Alcon Vivity, the Johnson & Johnson Vision Eyhance or the Rayner EMV. In the past, in the dominant eye I aimed for plano with the first myopic lens. With some longer data sets, I learned that it is better to aim for the first plus lens because the patient would be happier with a +0.2 D than with a –0.2 D with their distance vision. This is particularly true of the EDOF lenses that will give patients sharp 20/20 even if they are +0.25 D or +0.5 D because of the optics of the IOL.
Healio/OSN: How do you deal with residual astigmatism?
Donnenfeld: Whenever I deal with a patient who has residual astigmatism, I start by saying that this can be simply corrected with glasses if they do not want additional surgery. Almost no one chooses that option, but I want patients to know that this is a reasonable thing to consider. If patients want to have the best uncorrected vision, then we have to correct the cylinder, and there are three ways of doing that. In the cases in which we have implanted a toric IOL, we may need to rotate the lens to the correct axis, and I use the astigmatismfix.com online calculator for reorientation. If patients do not have a toric lens in place, for a small amount of cylinder up to 1 D, I perform limbal relaxing incisions. I use the Donnenfeld nomogram and my diamond knife, which makes it easy to perform these small limbal relaxing incisions. If residual cylinder is more than 1 D or if the patient has residual spherical refractive error as well as residual astigmatism, I perform LASIK or PRK, and that will solve the residual refractive error as well as treating larger amounts of cylinder.
Healio/OSN: How do you deal with the first of your C’s, which is ocular surface problems?
Donnenfeld: When a patient has ocular surface disease, I evaluate the tear film. I stain the eyes using lissamine green and fluorescein. I look at their lids and squeeze the lid margin to see if the oil glands have clear, turbid or even toothpaste-like secretions. I try to elucidate if the patient has aqueous-deficient dry eye or evaporative dry eye with meibomian gland dysfunction (MGD), and most commonly it is both. For aqueous-deficient dry eye, I use a short course of corticosteroids, preferably Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals), which is a low-dose nanotechnology corticosteroid. I commonly add an immunomodulator, such as cyclosporine or lifitegrast. Those two simple steps are effective for aqueous-deficient dry eye.
Many patients also have MGD, and I treat that with hot compresses and thermal pulsation using the TearCare (Sight Sciences), iLux (Alcon) or LipiFlow (Johnson & Johnson Vision) systems. I am a big believer in blepharoexfoliation using the BlephEx device (Alcon). In addition to hot compresses, patients may benefit from corticosteroids, so Eysuvis can kill two birds with one stone, treating both the aqueous-deficient dry eye and the MGD. The patients who have severe dry eye disease commonly have punctal plugs, and for significant MGD, I use azithromycin or oral doxycycline. Meibography is also helpful in these patients, and we have recently learned that Demodex may play a significant role in a lot of patients with ocular surface disease. We do not have any approved compound for Demodex right now, but blepharoexfoliation is helpful, and we are looking forward to the FDA approval of topical lotilaner (TP-03, Tarsus Pharmaceuticals), a neurotoxin for Demodex that appears to be helpful in treating MGD and dry eye.
Healio/OSN: Another of your C’s is centration. How do you fix it?
Donnenfeld: If the IOL shifts position, I recenter the lens, or I do an argon laser iridoplasty. I laser the iris to pull the pupil over the center of the IOL. I place four spots of 500 µm using 500 mW of energy, and I place them circumferentially in the axis where I want to move the pupil. This centration will commonly lead to improvement in quality of vision, which makes the patient happy.
Healio/OSN: Finally, how do you deal with patients who experience difficulties with neuroadaptation after cataract surgery?
Donnenfeld: That is the last pathway we explore once we have exhausted all organic possibilities for dissatisfaction. I explain to my patients that neuroadaptation takes time, particularly with multifocal IOLs, and I will generally not make recommendations for anything surgical to be done until 6 months after cataract surgery has been performed, assuming that the five C’s are all good. Neuroadaptation is a real entity, and I have seen routinely that patients definitely respond to time and improve. With patients who are mildly unhappy, I insist on waiting for 6 months, but I might go for an earlier intervention with those who are tremendously unhappy, particularly if I feel that they have unrealistic expectations and that no matter what I do, they are still going to be dissatisfied. In these cases, it is just more reasonable to do an IOL exchange on the earlier side. I explain to patients in great detail that they will be losing their reading vision and will have to accept this. There is nothing more frustrating than fixing a patient for dysphotopsia and having them be even more unhappy postoperatively because they have to wear reading glasses.
For more information:
Eric D. Donnenfeld, MD, can be reached at Ophthalmic Consultants of Long Island, 711 Stewart Ave., Suite 160, Garden City, NY 11530; email: ericdonnenfeld@gmail.com.
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