Eyeworld

62 | EYEWORLD | APRIL 2022 ATARACT C by Ellen Stodola Editorial Co-Director About the physicians Surendra Basti, MD Director of the Cataract Service Department of Ophthalmology Northwestern University Chicago, Illinois Daniel H. Chang, MD Cataract and Refractive Surgeon Empire Eye and Laser Center Bakersfield, California It is possible after surgery to be a little off from the target, Dr. Basti said, so it's important to mention to patients that they may have to adjust the distance at which they're reading. He always brings this up in the preoperative discussion. He is also very sensitive to treating dry eye preoperatively. "But sometimes a patient's eyes might look moist, and after surgery, they find the medication uncomfortable. So on our postop sheet, we spell out that they may have discomfort from the eye drops, and using artifi- cial tears is a good first line of defense." Dr. Basti said he doesn't overemphasize quality of vision in the preoperative discussion, but he will tell patients, "You can be fairly cer- tain if you don't like vision at end of this, there is the possibility of exchanging the lens." Dr. Basti said that this is done infrequently. Similarly to how Dr. Basti differentiated among the different complaints after cataract surgery, Dr. Chang suggested that these could be categorized as "visual" and "non-visual." Visual complaints, Dr. Chang said, include positive and negative dysphotopsias. Positive dysphotopsias, such as glare, halo, and star- bursts, are generally noticed at night when driving and are especially associated with pres- byopia-correcting IOLs. Therefore, it's important to counsel patients preoperatively and set ex- pectations. "As a rule of thumb, the more range of vision you provide, the more dysphotopsia you may create," he said. He added that it's im- portant not to proceed with the second eye until you're certain the patient is happy with the first. Dr. Chang said patients may see positive dysphotopsia early in the postoperative period due to capsular striae as well. He noted that the pressure change at the tip of IOL haptics can induce capsular striae and lead to starbursts. Since the capsule contracts within a few weeks, these dysphotopsias generally improve with time or can be fixed with a YAG laser. Negative dysphotopsia, which generally involves an arc or shadow in the temporal vi- sion, is a complaint that patients often express. Dr. Chang finds that around 1 in 5 patients will mention these symptoms. Generally, the better E ven with a technically perfect outcome after cataract surgery, physicians may find that some patients are unhappy. This dissatisfaction can be due to a number of factors that go beyond visual outcome. Surendra Basti, MD, and Daniel H. Chang, MD, shared what can cause unhappiness and how they discuss it with patients. Dr. Basti said it's not uncommon for patients to be unhappy after what is otherwise a success- ful cataract surgery. He said that about a quarter of patients who experience this dissatisfaction will not actually spell it out for the surgeon, but if you probe, you'll get to why they are unhappy. In the majority of these cases, Dr. Basti thinks it's a lack of proper understanding. "A proper conversation with the patient can poten- tially fix the source of unhappiness," he said. "Infrequently, there may be a need for surgery, but it depends on what the primary source of unhappiness is." Dr. Basti generally groups unhappiness after otherwise perfect cataract surgery into three categories. The first are patients whose refrac- tive outcomes or the point where they expect- ed vision to be is not exactly where it is. The patient may be a little more or less nearsighted than expected. It may be that the patient want- ed to be able to read, and the surgeon targeted a refractive error of –2.0 or –2.25, but some people are used to reading at different distanc- es than others. Frequently, it's the distance for working or using a computer that patients are not happy about, Dr. Basti said, estimating that half of unhappy patients after successful surgery would fall into this category. The second category of unhappy patients Dr. Basti sees are those with quality of vision issues. This group would include patients ex- periencing dysphotopsia and those with mul- tifocal lenses who don't quite like the contrast sensitivity. He estimated that around 30% of the unhappy patients he sees after cataract surgery fall into this category. The third category of patients unhappy after cataract surgery are those with physical discom- fort, like dry eye or a stinging sensation from eye drops, Dr. Basti said. This problem can usu- ally be corrected and isn't something that lasts. Unhappy patients after cataract surgery: Reasons for dissatisfaction and how to help continued on page 64

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