EyeWorld Asia-Pacific September 2015 Issue

41 EWAP REFRACTIVE September 2015 discuss issues like glare and halos and the chance that there will be a need for an IOL exchange. If the anatomy and physiology of the eye is not pristine, discuss that and make sure the patient understands, he said. “The second thing that leads to unhappiness is poor patient selection,” Dr. Berdahl said. It’s important to be aware of patients who may have a personality type that can’t tolerate the imperfections that come with every technology. For example, he said a subtle epiretinal membrane is not compatible with multifocality. Meanwhile, irregular astigmatism on the cornea does not work well with toric lenses. “If we’re not being diligent or screening for it or we believe that the technology is robust enough to handle these imperfections, we’re setting our patients up for disappointment,” Dr. Berdahl said. Dr. Hoffman said the most common reason for unhappy patients is unrealistic expectations. Another issue may be the inability to communicate intelligently with the patient. Screening tools Dr. Hoffman uses a variety of screening tools, starting with corneal topography to rule out surface pathology, angle kappa, irregular astigmatism, and pupil size. “There is no substitute for the physician talking one-on- one with the patient since many times this will reveal unreasonable expectations,” he said. “In addition, this gives the surgeon the ability to attempt to reset the patient’s expectations and feel out whether a particular patient will be happy with a mediocre result or unhappy with a good result.” He added that it’s a good idea to perform macular OCT to rule out subclinical retinal pathology, such as epimacular membranes and macular edema that might not be visible with a 90 D examination. “This is especially important for RLE with multifocal IOLs,” he said. Dr. Berdahl said there are 3 essential tools he uses for screening. These include topography, optical biometry, and OCT. Additionally, tools like wavefront aberrometry, the HD analyzer (Visiometrics, Terrassa, Spain) or iTrace (Tracey Technologies, Houston) can be helpful. Guidelines for tolerance of error and acceptable outcomes Dr. Hoffman recommended having postoperative residual astigmatism less than 0.75 D for refractive multifocal IOLs and less than 0.50 D for diffractive multifocal IOLs. Additionally, getting the postoperative sphere less than 0.50 D is usually fine, he said. An acceptable outcome is a happy patient, he added. “I have had patients with what I considered mediocre results with a postoperative refractive error of –0.75 D who were thrilled with their results,” he said. “I have also had an occasional plano patient who was unhappy because one eye saw 20/15 and the second eye was 20/20.” For this reason, patient selection is incredibly important. Being thorough can help the surgeon maximize patient satisfaction. “A full work-up including automated keratometry, topography, manifest refraction, complete slit lamp and biomicroscopy, retinal OCT, and a discussion regarding dysphotopsias, enhancements (and their cost if any), and potential complications are critical for maximizing patient satisfaction,” Dr. Hoffman said. An unhappy RLE patient Dr. Hoffman said that for unhappy postoperative patients, he does topography, including an examination of the mires to rule out surface distortion from anterior basement membrane dystrophy (ABMD). He will also do a careful refraction and slit lamp examination to look for IOL centration and posterior capsule opacification and folds, and a macular OCT to rule out cystoid macular edema. If patients are unhappy after a refractive lens exchange, Dr. Berdahl said that the first thing to do is to let them know that you care and that you’re there for them. “Once they know you care for them, finish,” he said. This could include doing an excimer enhancement if necessary, or if the patient is not tolerating the lens, an IOL exchange may be necessary. Top pearls for managing unhappy refractive patients Dr. Hoffman offered a number of valuable pearls for surgeons to manage their unhappy refractive patients. To begin, Dr. Hoffman recommended not operating on unhappy people, as they will likely be unhappy postoperatively as well. “Listen to patients and let them air their complaints without interruption,” he said. It’s important to let the patient be heard and to not belittle their concerns. “Give these patients unlimited access to your practice and to you,” he said. Offering the patient additional surgical procedures may be a valuable tool because it may help the patient feel that you are continuing treatment and not abandoning them. “Explain their pathology such as corneal dystrophy or macular edema, explain possible treatments, and keep talking to them,” he said. Finally, Dr. Hoffman recommended getting a patient’s spouse involved in the preoperative and postoperative process. “Sometimes patients don’t remember that you mentioned they might have halos for several months or might need an enhancement,” he said. “I am always relieved when a postoperative patient says they weren’t told about halos or some other complication and the spouse turns to them and confirms my comments.” EWAP Editors’ note: Drs. Berdahl and Hoffman have no financial interests related to this article. Contact information Berdahl : john.berdahl@vancethompsonvision.com Hoffman : rshoffman@finemd.com