FEATURE EWAP MARCH 2022 9 not worked well in Dr. Fram’s experience. Dr. Fram also mentioned a strategy reported by Folden6 and Cooke7 of using nasal capsulectomy, and her earlier research with Dr. Masket also indicated that nasal capsule was implicated in the etiology of negative dysphotopsia. However, many of the strategies such as ROC and sulcus placement move the optic forward and may fit with the ray tracing theory as well. Nasal capsulectomy has reduced rather then cured negative dysphotopsia in Dr. Fram’s experience. This may be a good strategy for a patient with a where you do not want to exchange the IOL and cannot ROC that particular IOL. Dr. Olson said that he tells patients to wait at least 6 months to give the brain time to adapt before pursuing any surgical options. He said that options for eliminating the capsule on the nasal side or moving the optic to the top of the capsule are both effective options. A piggyback can be effective, but you have to make sure you have plenty of room so you don’t get pigment dispersion. The key in these cases, Dr. Olson said, is to not think of negative dysphotopsia as “abnormal.” It’s part of what lenses do. Dr. Olson concluded by stressing several key principles. Let patients know ahead of time that this is common and normal. Physicians should be able to recognize what it is so they can help the patient. Dr. Olson also tells patients, “The more you’re concerned about it, the harder it is for the brain to ignore.” He tries to get patients to not worry too much about it because it will either resolve or can be addressed if it persists. EWAP References 1. Holladay JT, Simpson MJ. Negative dysphotopsia: Causes and rationale for prevention and treatment. J Cataract Refract Surg. 2017;43:263–275. 2. Osher RH. Negative dysphotopsia: long-term study and possible explanation for transient symptoms. J Cataract Refract Surg. 2008;34:1699–1707. 3. Coroneo MT, et al. Off-axis edge glare in pseudophakic dysphotopsia. J Cataract Refract Surg. 2003;29:1969–1973. 4. Masket S, et al. Surgical management of negative dysphotopsia. J Cataract Refract Surg. 2018;44:6–16. 5. Masket S, Fram N. Pseudophakic negative dysphotopsia: Surgical management and new theory of etiology. J Cataract Refract Surg. 2011;37:1199–1207. 6. Folden DV. Neodymium:YAG laser anterior capsulectomy: surgical option in the management of negative dysphotopsia. J Cataract Refract Surg. 2013; 39:1110–1115. 7. Cooke DL, et al. Resolution of negative dysphotopsia after laser anterior capsulotomy. J Cataract Refract Surg. 2013;39:1107–1109. Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California, and declared no relevant financial interests. Dr. Holladay is Clinical Professor, Department of Ophthalmology, $aylor College of Medicine, Houston, 6eZas, and declared no relevant financial interests. Dr. Olson is Chair, Department of Ophthalmology and Visual Sciences, ,ohn A. Moran Eye Center, 7niversity of 7tah, Salt Lake City, Utah and has interests with Perfect Lens, Perceive $io, and 6MClear. Negative dysphotopsia is one of those ghosts that can come to haunt you any time even after the most perfect cataract surgery. I read the comments by Dr. Holladay, Dr. Olson, and Dr. Fram, and I feel it is a very concise yet informative feature that explains the causation, risk factors, and possible treatment options for negative dysphotopsia. In my practice, I have seen that with better IOL designs, materials, and a better understanding of the problem, the incidence of negative dysphotopsia has reduced significantly. 9et, the odd patient does come up with the classical dark shadow. It is important to understand what we as surgeons can do to avoid or reduce this complaint. As we know, this is a phenomenon that is more likely to occur in high myopic patients with extremes of I"L power. urther, a significant overlap of the anterior capsule over the nasal IOL optic has also been incriminated. Therefore, particularly in myopic eyes, be mindful of the anterior capsulorhexis siâe. At the end of surgery, if I find that there is a significant area of anterior capsule covering the optic, I will enlarge the capsulorhexis in that half. Often, a patient will come to you having had surgery elsewhere and not happy due to dysphotopsia. In these situations, the most important thing to do is to reassure the patient and let them know that there is nothing wrong with either the surgery or the I"L. I find that once the patient knows that this is a known phenomenon and can happen despite the best surgical and visual outcomes, they are more receptive to the advice that you may give them. The other key thing in management is repeated sessions of talk time for the patient. I try and prioritize such patients when they come for their appointment and give them ample time, listening patiently to their problem. Once we become defensive, the patient also tends to become more offensive! Therefore, the best way is to hear them out, and discuss frankly what the possible options are for managing, first of them being wait and watch. I will typically wait for at least 3 to 6 months before planning any surgical intervention. My preferred approach would be to perform a reverse optic capture of the IOL optic through the anterior capsulorhexis, whenever possible. If not feasible, I would exchange the I"L with a sulcus-fixated I"L. When such a patient comes to you for the second eye surgery, discuss in advance that the same problem can occur in the fellow eye, and what you can do to prevent that from happening. I would choose an IOL design that is amenable to reverse optic capture or a threepiece IOL in the ciliary sulcus if it is a monofocal IOL being planned. In summary, from my experience of managing negative dysphotopsia, I find that honesty is the best policy. Be upfront about the uncommon possibility of this post surgery phenomenon, and after repeated counseling, maybe even asking for a second opinion, perform a reverse optic capture or IOL exchange if the problem continues to nag them. ditors½ note\ Dr. Samaresh Srivastava declared no relevant financial interests. Samaresh Srivastava, DNB Consultant Raghudeep Eye Hospital, Jaipur, India. samaresh@raghudeepeyeclinic.com ASIA-PACIFIC PERSPECTIVES
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