Managing unhappy presbyopia patients

Reviewed by John P. Berdahl, MD

With careful selection of candidates based on thorough preoperative evaluation and counseling combined with meticulous intraoperative technique, cataract surgeons have a high likelihood of achieving satisfaction among patients who choose a presbyopia-correcting IOL. However, the rare unhappy patient can ruin the day.

Understanding the patient’s complaints and knowing the potential reasons for patient dissatisfaction with a presbyopia-correcting IOL provides a basis for appropriate evaluation and successful management, said John P. Berdahl, MD.

“We really can get these patients to a place where they will be happy,” said Dr. Berdahl, assistant clinical professor of ophthalmology, University of South Dakota, and private practice, Vance Thompson Vision, Sioux Falls, SD. “To use a football analogy, we should not give up on them at the 3-yard line when we know that with some extra effort we can get them into the end zone.

“The first thing surgeons need to do is listen to the patient,” he said. “Not only will you get information that helps to determine the cause of the problem and therefore an effective solution, but it will make patients feel that you are on their team. To quote the wisdom of my grandmother: People don’t care what you know until they know you care.”

Refractive error is the most common cause of patient dissatisfaction with vision after presbyopia-correcting IOL implantation, but before addressing residual astigmatism or spherical error, cataract surgeons should look for and manage dry eye.

“This is a situation where listening to the patient’s complaints is very helpful for directing your care,” Dr. Berdahl explained. “If the patient reports having visual fluctuations, then dryness of the ocular surface is a problem, and treatment of residual ametropia will address the refractive error as it is measured at one point in time.”

Treating dry eye

Treatment for dry eye will depend on the cause and its severity. It may include lubricants, topical and oral anti-inflammatory medications, thermal pulsation, environmental and behavioral modifications, punctal plugs, and omega-3 fatty acid supplementation.

Because refractive error is a common cause for dissatisfaction among presbyopia-correcting IOL patients, surgeons who are offering this technology should be prepared to perform excimer laser enhancement procedures. Dr. Berdahl noted that in his practice, all patients are counseled preoperatively about the possibility of having another procedure, and the cost of a refractive touchup is included in the premium package.

Posterior capsule opacification (PCO) is another common issue underlying vision complaints among patients with a presbyopia-correcting IOL. Because IOL exchange is much more difficult once the posterior capsule is open, surgeons should be absolutely certain that PCO is a patient’s problem and that treating it is likely to make the patient happier with his or her vision.

Positive dysphotopsia, i.e., glare and halos, is another issue that patients may complain about after presbyopia-correcting IOL surgery.

Dr. Berdahl said that even though the risk can be mitigated by making sure that dry eye is adequately treated and by excluding patients who have high levels of corneal higher-order aberrations or irregular astigmatism, all patients receiving a multifocal or extended depth of focus IOL should be counseled about the potential for these visual symptoms.

“I tell my patients that by choosing these lenses, they are trading some visual quality for an increase in flexibility through decreased dependence on glasses,” he said. “I say they will likely have some glare and some halos and that the brain usually learns to adapt to these issues, just as it learns to filter out the shadow created by the edge of their frames or their nose when they look through their glasses.”

At the same time, however, he counsels patients that there is a small chance that they will find the problems persistently bothersome to the point where management would involve removing the presbyopia-correcting IOL and replacing it with a standard monofocal lens.

Exchange procedures

Dr. Berdahl said the cost of an exchange procedure also is included in the surgical package.

“It is hard to predict when an exchange will be needed, and we do not want to make these patients unhappier by charging them more for another procedure,” he said.

Some patients who choose a presbyopia-correcting IOL may be unhappy with the result if their best near point is not consistent with their visual needs. The best management for this problem is prevention, and that involves listening to the patient before the surgery.

Patients who want good uncorrected vision to do detailed near tasks, such as needlework, are good candidates for a higher add multifocal IOL, whereas someone whose needs are more for intermediate and far distances would be happier with an extended depth of focus or accommodating IOL, Dr. Berdahl said.

“Knowing the best near points for the different presbyopia-correcting IOLs is useful for recommending a lens that will match each patient’s visual goals,” he said. “In some cases, different lenses can be implanted in fellow eyes to give a patient a range of vision that will make them independent of glasses all of the time.

“However, I don’t ever promise freedom from glasses,” Dr. Berdahl said. “That may be my internal goal, but I always make sure patients accept the possibility that they may need to wear glasses some of the time.”

The “visually demanding” individual represents another scenario for patient dissatisfaction after presbyopia-correcting IOL surgery. Dr. Berdahl described this group as people who want ultra-crisp distance vision.

To screen for them preoperatively, he asks: “Are you visually picky?”

“Usually patients say they don’t know what I mean, and then I ask if when they got new glasses, they would return multiple times for adjustments,” he said. “If they say ‘yes,’ I explain that I am not sure they will be happy with a presbyopia-correcting IOL because I cannot make adjustments for them the way it was done with their glasses.

“I remind them that they have to decide if they are interested in increasing their visual freedom and flexibility in exchange for some decrease in visual quality,” Dr. Berdahl added. “Then, a presbyopia-correcting IOL might be a good fit for them.”

Patients who are still unhappy

Patients who are unhappy postoperatively with their distance vision are asked to look through a pair of -3.0 D glasses to show them the benefit they have with their presbyopia-correcting IOL.

Dr. Berdahl tells them that the lens can be exchanged to provide better distance vision, but that they will lose their ability to see without correction at near and intermediate distances.

“This demonstration reminds patients in a very tangible way of what they got with the IOL they chose,” Dr. Berdahl said. “Then I explain how time can be our friend before discussing an IOL exchange.”

John P. Berdahl, MD

E: john.berdahl@vancethompsonvision.com

This article was adapted from Dr. Berdahl’s presentation at the 2017 meeting of the American Society of Cataract and Refractive Surgery. He is a consultant to and/or receives lecture fees from companies that market presbyopia-correcting IOLs.