April 2014




Unsolved mysteries in ophthalmology

by Bonnie An Henderson, MD, cataract editor


Bonnie An Henderson, MD, cataract editor


The field of medicine is like a mystery novel. The etiologies and possible treatments of diseases are mysteries that are solved after years of arduous investigation of the clues. In ophthalmology, there are a few unsolved mysteries, one of which is the development of dysphotopsias after routine cataract surgery. Cataract surgery has undergone incredible advances in the past five decades. From implanting intraocular lenses, to phacoemulsification, to the birth of refractive cataract surgery with femtosecond lasers and presbyopia-correcting lenses, the innovations continue at a staggering rate. The far majority of patients are satisfied with the visual outcomes. However, a small percentage of patients have disturbing dysphotopsias, both positive and negative. The severity of dysphotopsias can range from minimal to debilitating. This month, we delve into these visual phenomena. Jack Holladay, MD, William Trattler, MD, and Jeremy Kieval, MD, describe the differences between positive and negative dysphotopsias. The symptoms of glare, halos, and arcs are common disturbances that can occur after cataract surgery and are considered "positive" dysphotopsias. Dr. Trattler warns that damage to the iris during surgery may lead to defects that allow additional light in and may lead to visual symptoms. He also recommends correcting any residual refractive errors and allowing sufficient time to neuroadapt before attempting to intervene. Positive dysphotopsias can occur after implantation of monofocal IOLs but are more often associated with multifocal IOLs. Richard Tipperman, MD, Audrey Talley-Rostov, MD, Douglas Katsev, MD, and John Berdahl, MD, describe their approaches to managing these symptoms in patients with multifocal IOLs. They describe how to choose the right patient, what other ocular conditions may increase the risk of dysphotopsias, and what treatments may be available postoperatively. A negative dysphotopsia is described as a blockage of light or a dark shadow often seen in the temporal periphery. The etiology of this phenomenon is more mysterious. In this issue, we are fortunate to have the world's experts continue the ongoing debate. James Davison, MD, Jack Holladay, MD, and Sam Masket, MD, review the possible causes of negative dysphotopsias. The advantages and disadvantages of the current treatments such as piggyback IOLs are discussed. David V. Folden, MD, and David L. Cooke, MD, present their data on the usefulness of a YAG anterior capsulotomy to improve the symptoms. Even new IOL designs are being created to decrease the risk of developing dysphotopsias.

If all else fails and the patient continues to experience dysphotopsias, an IOL exchange can be the final solution. Some surgeons prefer to cut, fold, or remove the IOL in one piece. Lisa Park, MD, and Richard Hoffman, MD, share their clinical pearls for performing a safe IOL exchange. While technological advances allow us to offer better refractive outcomes, safer procedures, and faster recoveries, some postoperative problems, such as dysphotopsias, continue to plague us. By sharing the past and recent discoveries in an open forum, perhaps novel solutions will arise and finally solve the mystery of the dreaded dysphotopsia.

Bonnie An Henderson, MD, cataract editor

Unsolved mysteries in ophthalmology Unsolved mysteries in ophthalmology
Ophthalmology News - EyeWorld Magazine
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