December 2018


Presentation spotlight
Managing unhappy patients

by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer

An eye with perfect centration of a PanOptix IOL (Alcon, Fort Worth, Texas) in the capsular bag after optic capture, taken 6 months after the operation. There was no refractive error, and the patient was happy with 20/20 vision.
Source: Mahmut Kaskaloglu, MD

Specialist speaks about precautions he takes before and after refractive surgery to keep his patients happy

Multifocal intraocular lenses (MFIOL) are largely chosen on the basis of matching patient criteria, although numerous factors come together to play an integral role in achieving optimum outcomes. Experts say that a careful and thorough preoperative examination is crucial in getting it right.
“For happy patients and doctors, I support a careful preoperative exam and evaluation. For the highest patient satisfaction, I strive for a complication-free surgery, and postoperatively, I am ready to deal with residual refractive errors,” said Mahmut Kaskaloglu, MD, Izmir, Turkey, in a talk he gave on the “Management of unhappy patients and the decision tree for selection of proper premium IOLs” at the 2018 World Ophthalmology Congress.
According to Dr. Kaskaloglu, time is the best remedy. “Post-refractive surgery care extends to not just hours or months, but it can be years. In my experience, most patients will adapt to the vision provided by MFIOLs—it just may take time,” he said. “Neuroadaptation is the key word, sometimes requiring more than a year’s time. It is important to assure and support the patient and maintain an open door policy for unhappy patients. Keeping the patient close to you is the best approach. In my practice, I find that most patients will not accept a lens exchange even if I offer it to them,” he explained.

Patient choice

“Post-LASIK patients are motivated for MFIOLs. We limit MFIOLs to patients who had LASIK for low refractive errors because LASIK for a small error will not cause significant spherical aberrations or HOAs,” Dr. Kaskaloglu said. “The question always seems to be whether to implant MFIOLs after LASIK. My answer is that LASIK is the treatment of choice for a small refractive error after MFIOL implantation, therefore, it is logical for us to be able to implant MFIOLs after LASIK for small refractive errors. Note that myopic LASIK induces increased postoperative spherical aberrations, therefore, an aspherical IOL with negative aberration is recommended for patients after myopic LASIK. Hyperopic LASIK induces negative spherical aberrations. In these cases, if ablation is central, which is not always the case in hyperopic cases, you can choose a MFIOL, but find a positive spherical aberration IOL if you can or zero aberration IOL.”
Dr. Kaskaloglu’s standout patient characteristics for MFIOL implantation include patients who do not want to wear glasses, those with easy-going personalities, and highly motivated emmetropic presbyopes. Negative characteristics include individuals who do not mind wearing glasses, hypercritical patients, certain professional groups, and low myopes.
“Often after a successful operation, the patient will come in with burning and stinging. Many will then tell you that they had this problem before the operation,” he said. “If you diagnose ocular surface disorders before the operation, it is the patient’s problem, but if you diagnose it after the operation, it is your problem. The best strategy is to carefully examine and question the patient beforehand for signs and symptoms of dry eye and meibomian gland dysfunction.”
Patients who complain about visual quality postoperatively without an ocular pathology need special attention. Dr. Kaskaloglu’s approach is to check refraction and prescribe glasses to gauge the situation, asking for the patient’s response after a few days. If feasible, he schedules LASIK and in the case of a refractive surprise, he will generally exchange the IOL. In cases of persistent glare and halos, he exchanges the MFIOL for a monofocal implant, however, if dysphotopsia is limited, he may choose to wait. With reduced contrast sensitivity, he recommends watchful vigilance, and before making the decision to exchange the MFIOL, he tries to find the real cause of the complaint.

Preop pearls

Ocular surface disorders: The tear film is the first refracting surface of the eye. The challenge is identifying ocular surface disease, as 40% of dry eye patients are asymptomatic, as are many of those with meibomian gland dysfunction (MGD).

Corneal surface: This can strongly influence postoperative comfort and vision. Note that preoperative keratometry and topography are affected by ocular surface disorders and cause IOL power errors. “Even a patient with perfect results may have complaints of foreign body sensation, burning, and fluctuating vision. Diagnose and treat dry eye and MGD before surgery and continue treatment after surgery,” Dr. Kaskaloglu said.

Specular microscopy: Dr. Kaskaloglu examines the eye for corneal guttata, noting that the severity of guttata is the key point. “A few scattered corneal guttata do not rule out a candidate for MFIOL implantation. Determine the severity of the guttata, especially in older patients. If they have only a few guttata you can overlook them and use multifocal IOLs,” he said.

Pupil shape and size: Surgical complications can arise in eyes with both large and small pupils. Small pupils can present surgical challenges during IOL implantation because of the need to stretch the pupil, which could encumber the centralized positioning of the IOL. Contraindications for MFIOLs include atrophic iris, eccentric pupil, iris coloboma, and atonic pupil.

Zonular issues: Success of MFIOL surgery ultimately depends on proper implantation and centration, hence patients with loose zonules, those with pseudoexfoliation, and individuals with previous vitrectomies are poor candidates.

Capsule tear: Although this can impede MFIOL stability, Dr. Kaskaloglu thinks that in certain case scenarios, a MFIOL can still be used, such as with a capsular bag that can be stabilized by a MFIOL with optic capture.

Macular disease: Good macular function is required to achieve optimal results with MFIOLs, and OCT is a must before the surgery. Eyes with epiretinal membrane, diabetic retinopathy, and AMD are not recommended for MFIOL, particularly if there are drusen near the fovea. According to Dr. Kaskaloglu, “Most patients are younger at the time they have a cataract or RLE operation. Ten percent may have AMD, 1–2% will have ERM within their lifetime, and we hope that better treatments are on the way. I will choose not to implant a MFIOL in eyes with diabetic retinopathy, but it is up to the surgeon and the patient to decide what to do.”

Biometry: Optical biometry and ultrasound should be used to examine eyes, implementing the proper formula and optimized A-constants to help achieve better results. Small refractive errors matter, in both sphere and cylinder, when considering MFIOLs, and he advised caution in adhering to the requirements. “Angle kappa is the angle between the pupil and the line of sight, but it is never zero. Avoid large angle kappa. In a large practice, angle kappa may be overlooked. Lastly, corneal wavefront HOA RMS over 0.50 µm is not suitable for MFIOLs, but it is not an absolute value. Coma and spherical aberrations may reduce visual acuity,” he said.

Editors’ note: Dr. Kaskaloglu has no financial interests related to his comments.

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