32 EyeWorld Asia-Pacific | September 2024 About the Physicians Allison Chen, MD | Assistant Professor, Cornea, Anterior Segment, and Refractive Surgery, Department of Ophthalmology, Baylor College of Medicine, Houston, Texas | allison.chen@bcm.edu Yvonne Wang, MD | Assistant Professor, Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, Connecticut | yvonne.wang.yw752@yale.edu Relevant Disclosures Chen: None Wang: None This article originally appeared in the June 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. REFRACTIVE SURGERY ASIA-PACIFIC PERSPECTIVES Robert Edward Ang, MD Asian Eye Institute 8th Floor, PHINMA Plaza, Rockwell Center, Makati City, Philippines angbobby@hotmail.com IOL exchange can be tricky. For me, the best tip is to avoid scenarios where it will be needed to begin with. Patient interviews can gauge the personality of the patient, which is probably the most important yet most subjective of all measures that can be taken. This is the reason why I insist on talking to patients to establish an understanding and to explain the surgery personally, rather than leaving it to a coordinator. Another important aspect is estimating the patient’s tolerance towards photic phenomena while discussing a diffractive multifocal IOL. Visual aids may be better for explaining the occurrence and intensity of these disturbances at night. Getting the right refractive outcome is the most important task during surgical planning. I would recommend using the tools within your control – diagnostic tests, biometry, IOL calculator, nomograms and past experiences with a particular IOL. The IOL will not work well and the chance of an unhappy patient is much higher if the refractive outcome is off-target. If the patient is still unhappy despite all these efforts, and wants the IOL removed, it would be important to be aware of this before the surgery of the second eye, or early on in the postoperative period. I agree that certain steps can be taken to salvage the situation, like treating dry eye and waiting a few months for neuroadaptation. If the reason is residual refractive error, laser refractive surgery may be an option to consider. Being ready with a three-piece IOL for sulcus placement or materials for scleral-fixation is part of the preparation for IOL exchange. It is crucial to advise the patient that IOL exchange carries risks and, in some cases, may necessitate more surgery or result in an outcome that is less desirable than what they have now. If you have little experience with IOL exchange, I also suggest you refer to a colleague. We have to look out for the welfare of the patient and that includes getting out of the driver’s seat and letting the patient know that someone more experienced can increase their chances of success or minimize complications. The article is full of useful tips to guide readers on planning and execution of IOL exchange. I particularly appreciate the differences in capsular bag fibrosis of the various IOL platforms that Dr. Chen described and will keep that in mind next time I dissect an IOL to release it from the bag. Editors’ note: Dr. Robert Edward Ang disclosed no relevant financial interests.
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