Unhappy patients have options after refractive cataract surgery
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When we talk about refractive cataract surgery, we are generally talking about giving the patient postoperative vision that provides an enhancement from the standard monofocal IOL with greater spectacle freedom.
That means potentially seeing near, intermediate and distance vision while reducing astigmatism and reducing the need for glasses after surgery. There are a number of ways to achieve this outcome.
Ophthalmologists can utilize specialty IOLs, namely extended depth of focus IOLs, multifocal IOLs, trifocal IOLs or toric IOLs. In such a manner, increased range of vision can be achieved with correction of astigmatism. In addition, monovision and mini-monovision can help patients achieve some degree of spectacle independence.
To help achieve accuracy, effective IOL position and astigmatism correction, femtosecond laser-assisted cataract surgery can lead to improved refractive results. In addition, other devices such as the ORA intraoperative aberrometer (Alcon) can help fine-tune the IOL power after cataract removal and provide a real-time Purkinje image during the surgical procedure to better align the toric IOL. In addition, new technologies are now available to utilize iris registry with femtosecond laser technology to automatically adjust for cyclorotation and improve marking the cornea for precise toric alignment. We also now have the ability to modify IOL power and astigmatism correction after surgery using Light Adjustable Lens (RxSight) technology. New accommodating IOLs are being investigated, such as FluidVision (Alcon), OmniVu (Atia Vision), JelliSee (JelliSee Ophthalmics), Lumina (AkkoLens) and Juvene (LensGen), to achieve accommodation without the visual distortions associated with competing multiple focal points.
Even with these enhanced technologies, ophthalmologist performing refractive cataract surgery will encounter the unhappy patient. Oftentimes, patients will be dissatisfied when their refractive result does not meet their expectations. This may be due to unrealistic expectations but also due to poor distance, intermediate or near vision. If the patient has residual refractive error or astigmatism, especially in conjunction with multifocal IOLs, they may experience unsatisfactory results. Finally, some patients with IOLs, but especially with multifocal or trifocal IOLs, may experience complaints of glare, halos, starburst, decreased contrast sensitivity, nighttime dysphotopsias, or just waxy or fuzzy vision.
As the director of cataract surgery at an academic center, patients will often seek my advice when they feel they have a poor outcome after cataract surgery. The first step is to evaluate the type of surgery that was performed on the patient and determine if there is some pathology that is causing their symptoms (eg, displaced IOL, residual refractive error and posterior capsular opacity) or simply unrealistic expectations. There are just some patients who are not able to neuroadapt to multifocal IOLs. Also, patients with other eye conditions such as dry eye, macular edema, epiretinal membrane or macular degeneration are often poor candidates for multifocal IOLs.
Rarely (usually less than 2%, but some studies have reported rates as high as 7% with older IOL technology), a multifocal IOL will need to be explanted. Patients do need to be informed that there are risks with IOL exchange, and if they have previously had a YAG capsulotomy, these risks are even higher. In addition, a replacement IOL may not be able to correct astigmatism, and a monofocal IOL will result in less range of visual acuity.
As ophthalmologists, we need to listen to what the patient desires, set realistic expectations before the surgery, and offer patients the different options depending on their lifestyle and any concomitant ocular conditions that are present. As in all refractive surgery, by setting reasonable expectations and utilizing our current advanced technology, we can achieve tremendous results and an extremely high rate of patient satisfaction.
Brian DeBroff, MD, FACS, is a professor of ophthalmology and visual science at Yale School of Medicine.
Click here to read the Cover Story, “Practices must prepare to offer refractive cataract surgery.”
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