Refractive: Opening doors
Winter 2025

by Liz Hillman
Editorial Co-Director

Nailing outcomes with presbyopia-correcting IOLs is important for many reasons—one of them being patient expectations, as they are paying out of pocket for an advanced-technology lens. But even when you’ve had an excellent surgery, postop complaints can trickle in, and the possible causes for the dissatisfaction are diverse.

Providing reassurance to the patient and identifying and managing the cause are paramount to maintaining a positive patient experience. “Multifocal IOL patients are the happiest patients in my practice, but rarely we do have patients who are unhappy, and it’s the unhappy patients who we remember,” said Eric Donnenfeld, MD. “Dealing with unhappy patients is the key to having a successful refractive cataract practice.”

“Presbyopic IOLs have improved markedly over the last several years, so the risk of unhappy patients is diminishing. But the corollary to that is that patient expectations have increased,” Dr. Donnenfeld added later.

Even though EyeWorld has covered this topic before, John Berdahl, MD, said it continues to be important. “We’re constantly improving refractive accuracy and dry eye management, so new challenges—like vitreous opacities—are becoming more prominent. And the treatment landscape keeps evolving, especially in dry eye. Each iteration of discussion helps us refine care and anticipate what’s next,” he said.

Step 1: Listen and identify

“My first step is always to really listen, validate their feelings, and make sure they know I genuinely want to help,” Dr. Berdahl said. “Patients can tell if you’re rushing them, so I set the tone early by showing I’ll take the time needed to solve their problem.”

Dr. Berdahl said the patient’s history often gives a strong clue as to what the source of dissatisfaction could be, but he also goes through the most common culprits systematically. “Residual refractive error and ocular surface disease are by far the most frequent issues, but I keep in mind that less common factors—such as posterior capsular opacification (PCO), vitreous opacities, or even neuroadaptation—can also play a role,” he said.

Dr. Donnenfeld said other team members will often hear the patient is unhappy with the lens before he does. He has empowered them to be able to order the appropriate tests—autorefraction, refraction, OCT of the macula, and topography—that could elucidate the problem.

“Why do I do that? Because when I walk into the room, I want to be able to tell the patient, ‘I know why you’re unhappy, I know what the problem is, and this is how we’re going to go about solving it,’” he said. “In the past, when a patient was unhappy, I’d walk in and be a little blindsided, and I would not have an answer for them because I wouldn’t know what the problem was. Now, I want to know what the problem is before I walk into the room. … That reassures the patient that I understand there’s a problem, I know exactly what it is, and I’m going to take the appropriate steps to solve it.”

Vance Thompson, MD, begins an appointment with an unhappy presbyopia-correcting IOL patient by reviewing with them the things that were covered preoperatively. He makes sure to discuss these possibilities with patients in preop appointments so there are no surprises.  “[This includes] that there is a healing process, and it is important to remember that if there is leftover correction, we do a fine tune at 3 months postop. If there is dry eye blur, we need to treat that, or if there is capsule haze causing blur, we need to do a YAG laser capsulotomy. If vitreous floaters are scattering light and degrading image quality, we need to take care of that,” he said.

Dr. Donnenfeld also brings the patient back through some of the drawbacks of the presbyopia-correcting IOLs that were discussed preoperatively, reminding them that what “they’re going to gain in quantity of vision is going to offset the loss of quality.”

Dr. Thompson reminds his patients that the process of neuroadaptation (the brain’s role) in the postop period can take 4–6 months. “I remind them we are embarking on a 1-year journey together, and at the end of that journey, they will have some of the world’s most sophisticated optics in their eyes. The patient joy can be so wonderful with these proper expectations,” he said.

Step 2: Treat, if needed

If the cause of dissatisfaction was identified in the clinic, it’s time to address it when possible. But first, Dr. Berdahl reiterated, these patients aren’t just frustrated—they’re often scared. “Acknowledging that fear and giving them a roadmap forward can be just as important as any therapy,” he said.

Dr. Thompson said if a quality manifest refraction is crisp, there is not much that can be done to improve the patient’s experience other than wait for healing, stability, and do an enhancement if there is residual refractive error.

If the manifest refraction is not crisp, “we need to bring our A-game,” Dr. Thompson said. “Tear film testing and treating dry eye helps image quality so much. I explain the air/tear interface and its power to focus light 2–4 times stronger than the actual implant we are putting in and that happy vision requires a happy tear film and implant,” he said.

Dr. Berdahl said that if dry eye is the issue, he emphasizes that this is chronic and fluctuating. He begins with punctal plugs, pharmacologic therapies, and often an eyelid thermal pulsation treatment. “The key is setting expectations; if they’re willing to work with me, I’ll work with them. At our clinic, our optometrists do most of the heavy lifting in dry eye management, but I stay involved to reinforce to patients that we’re in it together,” he said.

If after addressing dry eye the image quality is still reduced, Dr. Thompson will perform a YAG capsulotomy at 3 months if there is PCO. If there isn’t PCO, Dr. Thompson said he will do a gas permeable contact lens over refraction. “If that is crisp, we consider occult anterior basement membrane dystrophy, and we treat that with a corneal epithelial debridement often with a little PTK to establish a firmer epithelial adherence.” Epithelial remodeling from this procedure can take up to 3 months.

Dr. Donnenfeld said that he’ll also wait 3 months before performing a YAG capsulotomy for PCO, though he’ll consider it sooner if it’s significant and the patient was initially happy with their outcome. He noted that if patients were not happy with their presbyopic cataract surgery at the outset, the YAG might not completely solve their problem.

As for ocular surface disease and dry eye, Dr. Donnenfeld said this is one of the most important aspects of improving quality of vision after a presbyopia-correcting IOL surgery, and practices should have someone who manages these patients, whether it be an ophthalmologist or optometrist.

“When I see someone with a dry eye, I want to recognize the dry eye preoperatively,” he said. “I want to tell the patient they have dry eye. I want to treat it appropriately. Then if they have dry eye postoperatively, I explain that we’re going to continue to treat it, but we recognized it preoperatively.” Dr. Donnenfeld noted that if the patient has dry eye that cannot be resolved preoperatively, it’s a contraindication for a multifocal IOL.

If after 6 months postop image quality is still reduced, Dr. Thompson considers vitreous opacities and consults with retina. “Rarely, a vitrectomy is needed, and it is amazing how much it can help the patient’s image quality,” he said. Dr. Berdahl said for the right patient, vitrectomy for vitreous opacities can “dramatically improve satisfaction.” He said more is being done than it has been in the past.

Dr. Donnenfeld said he’s been interested in improving presbyopic IOL outcomes for the last 20 years, and for 18 of them, he ignored the contribution of the vitreous. “What I have learned subsequently is that the vitreous absolutely plays a significant role in patient quality of vision. And doing optical vitrectomies to improve quality of vision has been one of the greatest advances that I’ve seen in improving patient happiness and quality of vision with presbyopic IOLs.” Dr. Donnenfeld said he will wait a minimum of 3 months and optimally 6 months before referring for an optical vitrectomy for a patient who describes a blob moving across their line of vision. “What I hope is that blob will settle and move out of the visual axis, which does happen a lot. I encourage patients to wait 6 months when possible before I refer. And one of the caveats is that if I’m going to have the patient have an optical vitrectomy, I always do a YAG capsulotomy first.”

Despite these interventions, sometimes a LASIK touchup is necessary. There are times, rarely, that an implant exchange is needed to achieve patient satisfaction, Dr. Thompson said. “But if they understand the journey and we do our job completely, that should be rare. The patient satisfaction with modern-day advanced implants is amazing,” he said.

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About the physicians

John Berdahl, MD
Vance Thompson Vision
Sioux Falls, South Dakota

Eric Donnenfeld, MD
Ophthalmic Consultants of Long Island
Garden City, New York

Vance Thompson, MD
Vance Thompson Vision
Sioux Falls, South Dakota

Relevant disclosures

Berdahl: Alcon, Bausch + Lomb, Johnson & Johnson, RxSight
Donnenfeld: Alcon, Bausch + Lomb, Johnson & Johnson
Thompson: Alcon, Bausch + Lomb, BVI, Johnson & Johnson, Rayner, Zeiss

Contact

Berdahl: john.berdahl@vancethompsonvision.com
Donnenfeld: ericdonnenfeld@gmail.com
Thompson: vance.thompson@vancethompsonvision.com