CATARACT 22 EWAP JUNE 2023 Capsule stria are another source of patient frustration after cataract surgery, especially in the presence of a multifocal intraocular lens. Source: Kevin M. Miller, MD heard about this from a friend or relative. The reflection off someone’s eye after cataract surgery is different, and we can’t control it, he said, but if patients are concerned from an appearance standpoint, silicone IOLs are an option. Dr. Miller agreed that he doesn’t discuss every problem that can occur with patients. “One of the pieces of the psychology puzzle in complication management is that every patient after surgery wants to know why you didn’t spend more time talking to them about the complication they experienced,” he said. “They don’t care about the ones they didn’t experience. All they care about is the one they did.” Dr. Miller mentions halos around lights for patients getting EDOF and multifocal lenses. He will describe what it looks like. Halos can be bothersome in the first month or two, but patients may stop noticing them after a few months. “When I see patients a year later, virtually no one complains of halos, and almost all can drive well at night and see street signs,” he said. A pesky problem for ophthalmologists is when a patient comes into the office complaining of halos 3–4 months after surgery and there are wrinkles in the posterior capsule. You have to figure out if it’s the wrinkles or the lens design that’s causing the vision problem, he said, cautioning not to jump immediately to a lens exchange in these situations. Most times, opening the capsule fixes the problem. Dr. Miller mentioned several other problems that he sees after cataract surgery, including EBMD, CME, ptosis, corneal neuralgias, multifocal IOLs that are not centered in the pupil, and irregular astigmatism. He called CME “one of those things that haunts cataract surgeons.” It happens not infrequently in diabetics and patients with epiretinal membranes, but sometimes it happens in eyes that are totally normal. “When someone with any lens comes in a month after surgery saying, ‘My vision is blurry,’ and you look at the anterior segment and everything is clean, then you have to get an OCT or fluorescein angiography to see if there is CME,” he said. Dr. Miller noted the importance of documenting ptosis prior to surgery. “I can’t tell you how many times patients don’t see themselves well in the mirror before surgery, and they don’t know they have a droopy eyelid or wrinkles on their face. If you don’t mention ptosis or wrin-kles before surgery and they discover it after, they will wonder what went wrong,” he said. Corneal neuralgias are an underappreciated problem. “The patient comes in saying they have an irritation or foreign body feeling,” he said. “You look carefully and everything seems perfectly normal, then they come in again and again complaining of the exact same thing.” Patients with this issue often go from doctor to doctor. Sometimes the neuralgias resolve on their own, he said, adding that he usually waits about a year to treat. “I’ll have them massage the area where the incision is to see if this helps to get the cut nerve or nerves to stop misbehaving. If it doesn’t after a year, I’ll take them back to the operating room and recut the incision,” he said. “I’ll recut the incision proximal to the original incision, deeper and wider so I make sure I transect every nerve that went through the original incision, and it’s like magic.” Dr. Miller called this issue a “diagnosis of exclusion,” adding that “you have to make sure nothing else is going on.” When dealing with irregular astigmatism, Dr. Miller said it’s possible that there may be more irregularity to the cornea than previously known. You hope you pick this up ahead of time, he said, but it’s hard to predict the effect corneal irregularity will have on someone’s vision. “The 800-pound gorilla in the room is the cataract,” he said, adding that when you take the cataract out this could also impact the astigmatism, regular and irregular. In terms of when he addresses some of these issues after cataract surgery, Dr. Tipperman said for refractive errors, he tells patients to wait for the prescription to be stable (around 12 weeks). If the patient is continued on page 25
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