Cataract
April 2022
by Ellen Stodola
Editorial Co-Director
Even with a technically perfect outcome after cataract surgery, physicians may find that some patients are unhappy. This dissatisfaction can be due to a number of factors that go beyond visual outcome. Surendra Basti, MD, and Daniel H. Chang, MD, shared what can cause unhappiness and how they discuss it with patients.
Dr. Basti said it’s not uncommon for patients to be unhappy after what is otherwise a successful cataract surgery. He said that about a quarter of patients who experience this dissatisfaction will not actually spell it out for the surgeon, but if you probe, you’ll get to why they are unhappy.
In the majority of these cases, Dr. Basti thinks it’s a lack of proper understanding. “A proper conversation with the patient can potentially fix the source of unhappiness,” he said. “Infrequently, there may be a need for surgery, but it depends on what the primary source of unhappiness is.”
Dr. Basti generally groups unhappiness after otherwise perfect cataract surgery into three categories. The first are patients whose refractive outcomes or the point where they expected vision to be is not exactly where it is. The patient may be a little more or less nearsighted than expected. It may be that the patient wanted to be able to read, and the surgeon targeted a refractive error of –2.0 or –2.25, but some people are used to reading at different distances than others. Frequently, it’s the distance for working or using a computer that patients are not happy about, Dr. Basti said, estimating that half of unhappy patients after successful surgery would fall into this category.
The second category of unhappy patients Dr. Basti sees are those with quality of vision issues. This group would include patients experiencing dysphotopsia and those with multifocal lenses who don’t quite like the contrast sensitivity. He estimated that around 30% of the unhappy patients he sees after cataract surgery fall into this category.
The third category of patients unhappy after cataract surgery are those with physical discomfort, like dry eye or a stinging sensation from eye drops, Dr. Basti said. This problem can usually be corrected and isn’t something that lasts.
It is possible after surgery to be a little off from the target, Dr. Basti said, so it’s important to mention to patients that they may have to adjust the distance at which they’re reading. He always brings this up in the preoperative discussion.
He is also very sensitive to treating dry eye preoperatively. “But sometimes a patient’s eyes might look moist, and after surgery, they find the medication uncomfortable. So on our postop sheet, we spell out that they may have discomfort from the eye drops, and using artificial tears is a good first line of defense.”
Dr. Basti said he doesn’t overemphasize quality of vision in the preoperative discussion, but he will tell patients, “You can be fairly certain if you don’t like vision at end of this, there is the possibility of exchanging the lens.” Dr. Basti said that this is done infrequently.
Similarly to how Dr. Basti differentiated among the different complaints after cataract surgery, Dr. Chang suggested that these could be categorized as “visual” and “non-visual.”
Visual complaints, Dr. Chang said, include positive and negative dysphotopsias. Positive dysphotopsias, such as glare, halo, and starbursts, are generally noticed at night when driving and are especially associated with presbyopia-correcting IOLs. Therefore, it’s important to counsel patients preoperatively and set expectations. “As a rule of thumb, the more range of vision you provide, the more dysphotopsia you may create,” he said. He added that it’s important not to proceed with the second eye until you’re certain the patient is happy with the first.
Dr. Chang said patients may see positive dysphotopsia early in the postoperative period due to capsular striae as well. He noted that the pressure change at the tip of IOL haptics can induce capsular striae and lead to starbursts. Since the capsule contracts within a few weeks, these dysphotopsias generally improve with time or can be fixed with a YAG laser.
Negative dysphotopsia, which generally involves an arc or shadow in the temporal vision, is a complaint that patients often express. Dr. Chang finds that around 1 in 5 patients will mention these symptoms. Generally, the better the early postoperative visual acuity, the more they complain. “Computer modeling suggests that every pseudophakic eye has some arc of shadow on the retina, so it’s curious why some patients complain about it and others do not,” he said. Usually, you just have to reassure the patient. “The more I can preemptively describe the symptoms and resolution to the patient, the more it seems to diffuse their concerns,” Dr. Chang said.
Non-visual complaints include foreign body sensation, ptosis, and eyelid edema. Usually these symptoms improve with time, though they can sometimes drag on for a few weeks.
Patients may also be feeling the edge of the incision or even components of their eye drops, so it’s important to look for an abrasion, foreign body, or irregularity in the wound. “Typically, if they’re on drops, I suggest that they wait until after they finish drops before investigating further,” Dr. Chang said.
Preop counseling and trials
Dr. Basti said he doesn’t generally do a contact lens trial prior to surgery because it’s often hard to simulate quality of vision with a cataract in the eye. What he will do is discuss with the patient the distances at which he or she likes to hold things. “But beyond that, I don’t try to do too much simulation.”
Dr. Chang said that he doesn’t do lens trials because he doesn’t put someone in monovision who hasn’t been in monovision before. His preferred approach is the use of EDOF or hybrid IOLs that give a fuller range of vision, so both eyes have distance, compared to monovision where there is a discrepancy, he said. This approach likely minimizes the risk of falls due to loss of contrast and depth perception, he added.
When counseling patients preoperatively, Dr. Chang doesn’t mention every possible complication that can occur because he doesn’t want to overload the patient. Other than a discussion of positive dysphotopsias with patients electing presbyopia correction, “the six things that I point out to all cataract patients are swelling, inflammation, retained lens fragment, retinal detachment, bleeding, and infection.” He finds that patients will generally adapt to other visual disturbances as long as they’re aware that their symptoms are not the manifestation of a surgical or postoperative complication.
Deciding when to intervene
Dr. Chang said that most patients will know by postop day 1 if they have any of these issues. For those who received presbyopia-correcting lenses, he will see them at week 1 as well.
For patients receiving monofocal lenses, Dr. Chang said he generally doesn’t see them between eyes; if they do have a complaint, he makes sure the issue is addressed before operating on the second eye. The second eye rarely needs to be postponed.
Deciding whether to remove a lens is probably the most difficult management decision with presbyopic lenses, Dr. Chang said. Fortunately, most issues can be resolved with treatment of dry eye, a refractive enhancement, and/or a YAG laser capsulotomy. He will typically wait several months before proceeding with an exchange. For symptoms of negative dysphotopsia, Dr. Chang said he would wait at least 6–12 months before considering any surgical intervention, which he has never had to do.
If surgical intervention does become necessary after cataract surgery because the patient is unhappy, Dr. Basti said it’s important not to make decisions on lens exchange in the first months after surgery. Patients need to be given some time, and sometimes they just need to have a better understanding of the situation and explore it before making a big decision to exchange a lens.
“I almost never intervene in the first month,” he said, adding that 3 months is about the time he thinks the patient needs in order to adapt or at least give it a true attempt.
For those with dryness, routine postop drops have usually stopped around this time, he said, and many patients with dysphotopsia will see it resolve after several months as well.
For those with problems that still persist, Dr. Basti again stressed that there is the possibility of surgically exchanging the lens.
“For someone unhappy with the outcome, convey to them that you will continue to monitor and get them to a good place,” he said. “Providing that reassurance is key here.”
About the physicians
Surendra Basti, MD
Director of the Cataract Service
Department of Ophthalmology
Northwestern University
Chicago, Illinois
Daniel H. Chang, MD
Cataract and Refractive Surgeon
Empire Eye and Laser Center
Bakersfield, California
Relevant disclosures
Basti: Johnson & Johnson Vision
Chang: AcuFocus, Johnson & Johnson Vision
Contact
Basti: sbasti@northwestern.edu
Chang: dchang@empireeyeandlaser.com
