CATARACT EWAP JUNE 2023 21 Now you have a dilemma, Dr. Miller said, of how much of the problem is refractive error and how much is the capsule. He will often wait to do a refractive touch-up until he’s opened the capsule. There are different challenges and expectations depending on which lens the patient had implanted. “When you implant a multifocal lens, you can be pretty sure the patient does not want to wear glasses,” he said. “Their expectations and the bar you have to exceed are higher.” Monofocal patients have often resigned themselves to wearing reading or computer glasses. “With a multifocal, it’s a little harder sell to put them into glasses, but I tell patients that if all you need is a little help for nighttime driving, let’s just do glasses.” It’s a much simpler option than more surgery. Dr. Miller finds that a portion of his multifocal patients admit that they need a little help at nighttime and will use glasses, but there are some who don’t want to wear glasses for any scenario. “For those, we do laser vision correction,” he said. “In my location, among our premium services, we offer postop refractive enhancement as a service a patient can opt for.” He noted that patients do not have to sign up for this option, but it’s like an insurance policy. “Our standard cost for laser vision correction is $2,500 per eye,” he said. “If someone signs up for this insurance service, they pay $500. If they need or want laser vision correction after a cataract operation, they get it for $500.” Dr. Miller noted that there are some surgeons who start to build a premium practice not thinking about what they are going to do when they encounter their first unhappy postoperative patient. They often feel they’ve been burned and don’t think it’s worth the effort. This is one reason why the device industry isn’t seeing much growth in the premium lens market, he said. If you have a strategy to deal with postoperative refractive errors and can get good results using that strategy, there’s no reason not to forge ahead. Dr. Tipperman added that small residual refractive error can be incredibly frustrating to deal with for the surgeon and the patient. “The new generation formulas are good, and our techniques are good, but not every person gets to plano 20/20, and patients often cross cover each eye and compare them.” There are some patients who you know preoperatively are going to be very particular, Dr. Tipperman said. “Those are people with whom I’ll have a more prolonged discussion Glistenings do not usually reduce visual acuity, but they can cause light and glare sensitivity. This lens is a florid example; most cases are more subtle. Source: Kevin M. Miller, MD about biological systems, healing, the lenses only coming in half D steps. … I tell them that ophthalmologists hate the word ‘perfect’ because it can’t always be achieved,” Dr. Tipperman said. He thinks those are patients in which the Light Adjustable Lens (RxSight) is a technology that you can offer them. Other issues that can come up after surgery are capsular striae, wrinkles, and unwanted optical images. “The classic one is someone who has a capsular fold, and they see a light of 90 degrees to where the fold is,” he said, noting that he tells patients that this often resolves on its own. But if the patient is 12 weeks or so postop and still bothered, Dr. Tipperman will use a YAG laser. Other patients might undergo cataract surgery and everything looks perfect, but they have significant glare and streaks of light in all directions postop, Dr. Tipperman said. “I see those patients treated with a YAG capsulotomy, and they’re always worse after that. I don’t think it’s well understood what causes the glare and streaking in otherwise perfect surgery.” Those patients are frustrated and think there’s some sort of defect with their lens, so it’s important to spend a lot of time with them. “I think if you do a YAG on those patients, you can make things worse because dysphotopsias become worse, and exchanging them becomes a bigger problem,” he said. When having a discussion preoperatively with the patient, Dr. Tipperman noted it’s impossible to mention every single problem that can occur. However, for those patients who say they want to have “perfect” vision, Dr. Tipperman will reiterate that “we can only make it so good,” and if they’re not happy, there are ways to make it better. Dr. Tipperman said he doesn’t normally discuss unwanted optical images unless the patient brings them up. Depending on anterior chamber depth, you will see a much more obvious reflection off the IOL than off a natural eye, and Dr. Tipperman said patients often ask about this. Many have
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