FEATURE EWAP JUNE 2022 13 can’t get to 100% within ±0.25 D with any presbyopic IOL solution, so enhancements are critical.” Case example Dr. Raviv provided a case to illustrate how he used his algorithm. Three weeks after receiving a trifocal toric IOL, a patient was in his office complaining of a ºfilm» and “blurry/hazy” vision. Dr. Raviv said the patient had some dry eye preop and had been on topical cyclosporine for a month. First, he refracted the patient. She was correcting to 20/25- with a slight myopic correction. “Since the BCVA wasn’t a crisp 20/20, we pursued treatment to improve the vision,” he said, noting that OCT showed the macula was yat and unchanged and there was no significant P O. ºThere was some punctate corneal staining. The topical steroid was increased and NSAID was discontinued. Restasis [cyclosporine, Allergan] and preservative-free tears were maintained.” At 2 months postop, the patient’s BCVA with a –0.75 D improved to 20/20. From there, Dr. Raviv did an in-office contact lens trial, in which the patient noted significant improvement in distance and near vision. The plan was to continue dry eye drops for a few months, then proceed with PR . At postop month 4, BCVA was 20É{0- and 1³ P O was present. A 9A capsulotomy was performed followed by another refraction. Dr. Raviv then performed PR . One month after PR , the eye was plano 20/20 (and J2), and the patient was very happy, Dr. Raviv said. Other perspectives Blake Williamson, MD, shared his perspective on patients who are unhappy after cataract surgery. He said the question is in what percent of the lenses that you place is there unhappiness such that the surgeon needs to do something about it? Dr. Williamson said his explant rate is less than 1%. “I think that’s a testament to how we educate the patients on the preop side, making sure they understand the limitations, set appropriate expectations, pick the right patients, etc.,” he said, adding that if surgeons are using presbyopia-correcting lenses, they should have the skills to explant or perform a touch-up or be prepared to refer should the need arise. Reasons for patient unhappiness can be any number of things. Dr. Williamson said often it’s an issue between eyes. “It’s like having a cowboy boot on one foot and a roller Avery interesting perspective has been shared by Dr. Tal Raviv on his strategy of handling an unhappy postoperative patient after a presbyopia correcting IOL. With the introduction of the new generation trifocal IOLs, the incidence of unhappy patients has been significantly reduced. The most common cause of an unhappy patient is residual ametropia, particularly astigmatism, and I would urge all colleagues to do a toric IOL calculation for each eye using the Barrett’s Toric Calculator, and try and correct the least amount of astigmatism that can be treated with a toric IOL. I would always forewarn patients during preoperative counseling that there is nothing like a “zero number” and all patients are likely to have some residual number even after the best surgery; however, very few require the need to use them after binocular surgery. It is very rare to get a very gross refractive surprise. I would be very hesitant in doing any form of laser vision correction on these patients as I do not want a multifocal cornea over a multifocal IOL, and since the majority of these patients are elderly, there is a significant worsening in their dry eye status. -o, if correcting the residual refractive error makes them happy, I would not hesitate in prescribing a pair of glasses which they can use in selective activities. I also believe 9A capsulotomy is being advocated far too liberally in patients with multifocal IOLs. One must remember the consequences of 9A capsulotomy in terms of increased incidence of retinal detachment, and also the fact that it would be very difficult to then perform an exchange of IOL if required with an open posterior capsule. 1nless the P O is severe, which it rarely is in the early postop period, I would rarely perform a 9A . I would consider IOL exchange only in very rare cases where the patient is eÝtremely bitter after the first eye. I would eÝplain to such a patient that an IOL exchange surgery could have its own complications such as âonular compromise, P R, corneal edema, and ME, and that he will now need glasses for both distance and near. I have found that talking to patients at every visit, listening to their same complaints every visit, not being defensive in our approach and yet reassuring them that there is no serious vision-threatening condition in their eyes, eventually helps me to win over these patients over a period of time and avoid any form of second surgery with its potential risks. ditors½ note\ r° 6asaÛada deVlared no releÛant finanVial interests° Shail Vasavada, MD Consultant Ophthalmologist, Raghudeep Eye Hospital, Ahmedabad, India shail@raghudeepeyeclinic.com ASIA-PACIFIC PERSPECTIVES
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