REFRACTIVE EWAP MARCH 2024 23 ZEPTO IOL Positioning System (Centricity Vision), which makes a precise, round capsulorhexis, may help, he said. Some patients may experience a major decentration, rather than just a minor issue. These major decentrations would likely come from a surgical complication, Dr. Ayres said, like a severe zonulopathy or posterior or anterior capsular tear. Patients may notice reduced vision, double images, or dysphotopsias due to reflections off the edge of the lens implant. “The problem we have is fixing that IOL or replacing it with a new lens using an alternative technique, the common one being the Yamane technique or some other form of scleral-fixated IOL. The decentration and tilt are still a problem, and we’re placing a lens in the absence of capsular support, and there is not a device or IOL that is specifically made for and designed for non-capsular placement,” Dr. Ayres said. “We do all sorts of measurements preoperatively and in the operating room, trying to pick the best technique for that patient. At the end of those surgeries, sometimes you look through the microscope, and even with all the measuring, it still looks a little decentered or tilted, and the repair for that can be difficult.” In addition, Dr. Ayres said, all the techniques used are technically off label. “We have very good techniques, but they’re less accurate when it comes to biometry, and it’s easier to get decentration and tilt.” Patients are already worried about their vision and know they have a complex ocular problem. The fear and frustration level escalates when in some cases patients need to return due to decentration of the implant. Proper counseling and a good doctor-patient relationship is required to maintain trust in these situations. In addition, it’s your responsibility to manage both the patient’s condition and help the referring physician manage their relationship, Dr. Ayres said. Many times you’re starting out with a frustrated patient, so it’s important to try to and improve the patient’s outcome and inform them that there is no cookbook recipe for managing complex problems. Even the best surgical solutions may have complications and frustrations. Decentration problems can occur both immediately after surgery or down the line, Dr. Ayres said. He gets calls from doctors during surgery or postop day 1 trying to get the patient a follow-up visit to manage the situation. There are also late dislocations, where the surgery 20 years ago was fine and now there’s a zonulopathy (maybe the patient had a vitrectomy or has pseudoexfoliation), and the current lens is dislocating or tilted. In these cases, we’re either trying to reposition the existing lens or exchange it for a new one, Dr. Ayres said, which would have to be an anterior chamber lens or an IOL fixated to the sclera, and you run into the same challenges trying to ensure the new lens is properly centered without tilt. EWAP References 1. de Castro A, et al. Tilt and decentration of intraocular lenses in vivo from Purkinje and Scheimpflug imaging. Validation study. J Cataract Refract Surg. 2007;33:418–429. 2. Rosales P, Marcos S. Phakometry and lens tilt and decentration using a custom-developed Purkinje imaging apparatus: validation and measurements. J Opt Soc Am A Opt Image Sci Vis. 2006;23:509–520. 3. Marcos S, et al. Three-dimensional evaluation of accommodating intraocular lens shift and alignment in vivo. Ophthalmology. 2014;121:45 – 55. 4. Sun M, et al. Intraocular lens alignment from an en face optical coherence tomography image Purkinjelike method. Opt Eng. 2014;53:061704. Editors’ note: Dr. Ayres is Co-Director of the Cornea Fellowship Program, Wills Eye Hospital, Philadelphia, Pennsylvania, and has interest with Alcon, Bausch + Lomb, and Carl Zeiss Meditec. Dr. Marcos is Professor, Department of Ophthalmology, University of Rochester Medical Center, Rochester, New York, and is co- inventor in patents for anterior segment OCT quantification, crystalline lens shape measurement, and estimated lens position from OCT. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. LESSONS LEARNED Kevin M. Miller, MD, EyeWorld Cataract Editorial Board member: I have increasingly come to appreciate a facet of human behavior that is on full display before and after surgery, especially cataract and refractive surgery. It is that the patient’s frame of reference changes after surgery. What would have been a 1 or 2 complaint on a 0–10 scale before surgery becomes an 8 or 9 after surgery. People quickly forget how badly they had it before surgery, and the little things that didn’t bother them all that much before surgery suddenly become “big problems” after surgery. Surveys are where you see this behavior on display the most. I have been involved in multiple artificial iris device trials. We always rate photosensitivity, glare, halos, etc., before and after surgery. There is no question that iris devices help reduce all these symptoms. Someone may state their symptoms are a 7 out of 10 before surgery and a 6 out of 10 after surgery. How can that be? I remind them: “You said your symptoms were a 7 out of 10 before surgery, and now they are a 6 out of 10. So the surgery and iris device didn’t help you that much, correct?” The patient will say, “No, I am much better off now. I’m so happy I had the surgery!” Then I ask, “If you were a 7 before surgery, what are you now?” The patient will answer, “Maybe a 0 or 1.” This frame of reference change happens all the time. In order to get at the truth, we need to remind patients how they rated their symptoms (or how bad their vision was without glasses, how poor their reading vision was, etc.) before surgery. Otherwise, they confuse you by subconsciously changing their frame of reference.
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