June 2015

 

CATARACT

 

Whats my line?: Pearls for effective patient communication

Pseudophakic dysphotopsia


 
 

Craig N. Piso, PhD

Three expert ophthalmologists share here how they communicate with patients experiencing dysphotopsias following successful cataract surgery and where no pathological etiology is found. Since forewarned is forearmed, notice the use of anticipatory guidancesetting non-threatening expectations preopso patients are less likely to become unduly alarmed postop. As you read their suggested verbiage for handling these symptoms when no pathology is present, be looking for their skillful use of these helpful communication principles: 1)

Our perception defines our reality: It makes no sense to argue with patients about what they are seeing or experiencing since, like beauty, it is subjectively perceived in the eye of the beholder. Accordingly, normalizing their experience, and thus validating their report, will calm most patients and liberate them to follow your lead, rather than battling you to make their point.

2)

What we focus upon tends to expand: The more a patient becomes anxious about any unwanted visual images and, therefore, remains visually fixated upon them, the more likely it is that these symptoms will continue because such preoccupation interferes with neuroadaptation and their typical cessation over time.

3)

Self-fulfilling prophecy: Once a patient understands and accepts the expectations youve set, they become psychologically invested in making your predictions come true, at least unconsciously, which explains a great deal about the efficacy of pharmacological placebos. Therefore, ophthalmologists can tap into this unconscious process by setting positive, reality-based expectations in order to mobilize the patients psyche to augment the desired outcomes.

Craig N. Piso, PhD, Whats my line? editor

 

Lisa Arbisser, MD

Lisa Brothers Arbisser, MD

Adjunct associate professor, Moran Eye Center, University of Utah, Salt Lake City

When patients complain of dysphotopsia, we must first be sure they are not retinal in origin. Full confrontation fields and the assurance that positive dysphotopsias are only experienced with eyes open, not closed, is sufficient, along with the classical temporal arc of the negative dysphotopsias. I explain to patients: Even the most modern technology cannot exactly mimic the young natural lens that God or nature gave us. Before your cataract developed, causing your lens to get cloudy, the lens let almost all light go through without bouncing back. Our man-made materials, which allow you to see so clearly, are most often made of a type of plastic called acrylic. This substance is more reflective than the natural crystalline lens. Although most of the light goes through, some bounces back, causing what we call unwanted visual images, interpreted by the brain as glints or glimmers or a curved dark shadow to the side. About 30% of people will notice this after uncomplicated cataract surgery, sometimes in just one eye and sometimes in both. Even though your pupil is this big [I show them a small circular opening with my fingers] and the lens is this big [also demonstrated as much larger] certain rays of light, mostly from above, can come through the pupil and bounce off the edge of the implant, resulting in an image that isnt really there like the image in the mirror isnt real. I then check their side vision by confrontation, showing them how this virtual image doesnt block their vision at all. If they are aware of the image while we are talking in the lane, I will place my hand like a visor over their brow, blocking the light from the ceiling illumination, which always makes the negative dysphotopsia briefly disappear. This assures them of the veracity of my explanation.

I then say, Although 30% of people will notice this, less than 1% are bothered long term. Modern surgery involves opening the front bag of the cataract, removing the cloudy protein, polishing the back bag, and placing the man-made lens in this bag. Over time and with healing, the bag shrinks around the new lens, decreasing the space for the unwanted stray light rays to enter and protecting the lens edge so it gets less glinty. This may cause the images to go away completely. One more reason so few people are bothered for long is that the brain is a smart organ that learns to tune out noise and tune in information. For the very small percentage of people who are bothered long term there are surgical solutions but they are not without risk. I would be happy to discuss these details further and would expect to hear if you have an ongoing problem. So dont let it strike fear in your heart if you notice these images; theres nothing wrong that needs attention. Your goal is to ignore them as best you can, knowing they will likely either disappear or fade from consciousness unless you look for them actively out of curiosity. Do you have any questions, anything thats not well understood? It is very important that the whole staff understands this issue and that the patient hears the same explanation from the staff and the doctor.

Susan M. MacDonald, MD

Susan M. MacDonald, MD

Director of comprehensive ophthalmology, Lahey Clinic, assistant professor, Tufts University School of Medicine, Boston

After a successful cataract surgery, we anticipate happy patients, yet with dysphotopsias patients seem unimpressed with their new vision and are unhappy, focusing on these new peripheral visual symptoms. This can be a frustrating experience for both the patient and the ophthalmology team. Patients can be made to feel as if their symptoms are all in their head and they are being dismissed. The ophthalmology team can judge the patient as a complainer and ungrateful. It is a setup for miscommunication, misinformation, and an unhappy patient.

One of the most important things the ophthalmologist can do is lead by example and set the tone of how this patient is to be treated. When I hear a patient is complaining or being picky about streaks or peripheral glare, I remind myself and my team that these are legitimate concerns, and the patient may be afraid and worried. It is our responsibility to help this person with our kindness, patience, and explanation.

Giving the patient an opportunity to describe the symptoms is useful. I then ask a few pertinent questions to hear what they are worried about and to further classify positive or negative dysphotopsias. I will then let them know that we are going to evaluate their eye and make sure there is no serious condition, such as retinal detachment, causing the symptom. I will follow this with a thorough exam of the anterior and posterior segment.

Once I have determined there is no underlying pathology, I share this information with the patient: There is good news. Your eye is healthy and I am happy to report I did not find any retinal pathology such as a detachment, peripheral tumor, or neurologic lesion causing visual field loss. I spend time on this because it is important to emphasize the positive and to try and reduce anxiety and fear.

I will then explain what a dysphotopsias is and give a basic description of the optics of the eye. I will remind the patient of our preop discussion about the visual system and the limitations of lens technology. I say that many people will have some odd visual phenomenon postoperatively, and this is a period where the eye and cortical visual system are adjusting. The lens is a new part of your visual system, it is man-made and not perfect, but as your brain adapts (neuroadaptation), most times symptoms fade. I suggest that the patient can help this symptom fade by not focusing or ruminating on it. When they notice the phenomenon they should tell themselves it is nothing to worry about and stop focusing on it.

The good news is most people are able to learn to adapt and integrate these lenses into their visual system. I will give you some tips on how to do this. Most have to do with keeping both eyes open and not testing your eyes, not looking for the phenomenon. The second part is when you do experience this, tell yourself it is nothing to worry about. Removing the anxiety associated with the symptom will reduce the brains focus on it. Finally I say that rarely, we find a patient who is terribly bothered by persistent dysphotopsias and this patient will need to consider further treatment. For positive dysphotopsias we will try a miotic agent such as pilocarpine 0.5% or brimonidine 0.15% For patients with negative dysphotopsias I will offer them the miotic treatment and expect it will probably not be useful but worth trying.

If we have tried the above and the patient is still very unhappy, we will discuss IOL exchange and repositioning. I prefer to do an IOL exchange repositioning within the first 6 months. I discuss the risks and benefits with the patient. I rely on the work of Sam Masket, MD, to guide me on the treatment approach. I will have a plan that will include a few options. One is to remove the lens and replace it with a sulcus 3-piece IOL with optic capture; the second option is reverse optic capture of the original IOL; and the third option is a piggyback sulcus 3-piece IOL.

My clinical experience has led me to believe that these patients are not difficult patients, but they are usually a bit scared, frustrated, and nervous. They are appreciative of you listening to them and treating their dysphotopsias. They are our patients and deserve our time and assistance.

Jack M. Dodick, MD Jack M. Dodick, MD

Professor and chairman, Department of Ophthalmology, New York University School of Medicine, New York

I tell my patients before surgery: You may experience a dark shadow, flashes, or halos shortly after surgery, but these eventually disappear. I tell my patients after surgery, when they report these symptoms: It is as if you are experiencing a dark arc at the side of your vision or on occasion a flash or halos. To this day we are not certain what causes these symptoms but I do know that they are of no concern and will eventually disappear. We do not understand it well, but think it is a reflection of light from the edge of the lens and is quite common. It may also be related to the size of your pupil, which is why some patients report it more frequently than others. However, as the eye heals, it fades away. The reason I start the conversation by reiterating their symptoms in my own words is to impart a sense of I understand exactly what you are describing, am familiar with the symptom, and I am not concerned about it. I dont feel compelled to go into a lengthy description of causative theories such as truncated lenses because we still do not fully understand the root cause of the symptom. This statement is truthful. To go into explanation of theory, such as lens design, can raise the concern for patients of a faulty lens.

I do counsel my patients on the symptoms of retinal tear and detachment and how they differ from these symptoms and the importance of immediately reporting them.

Editors note: The physicians have no financial interests related to their comments.

Contact information

Arbisser
: drlisa@arbisser.com
Dodick: Jackdodick@aol.com
MacDonald: susan.m.macdonald@lahey.org

Pseudophakic dysphotopsia Pseudophakic dysphotopsia
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