Eyeworld

64 | EYEWORLD | APRIL 2022 ATARACT C Contact Basti: sbasti@northwestern.edu Chang: dchang@empireeyeandlaser.com Relevant disclosures Basti: Johnson & Johnson Vision Chang: AcuFocus, Johnson & Johnson Vision the early postoperative visual acuity, the more they complain. "Computer modeling suggests that every pseudophakic eye has some arc of shadow on the retina, so it's curious why some patients complain about it and others do not," he said. Usually, you just have to reassure the patient. "The more I can preemptively describe the symptoms and resolution to the patient, the more it seems to diffuse their concerns," Dr. Chang said. Non-visual complaints include foreign body sensation, ptosis, and eyelid edema. Usually these symptoms improve with time, though they can sometimes drag on for a few weeks. Patients may also be feeling the edge of the incision or even components of their eye drops, so it's important to look for an abrasion, foreign body, or irregularity in the wound. "Typically, if they're on drops, I suggest that they wait until after they finish drops before investigating fur- ther," Dr. Chang said. Preop counseling and trials Dr. Basti said he doesn't generally do a contact lens trial prior to surgery because it's often hard to simulate quality of vision with a cataract in the eye. What he will do is discuss with the patient the distances at which he or she likes to hold things. "But beyond that, I don't try to do too much simulation." Dr. Chang said that he doesn't do lens trials because he doesn't put someone in monovi- sion who hasn't been in monovision before. His preferred approach is the use of EDOF or hybrid IOLs that give a fuller range of vision, so both eyes have distance, compared to monovi- sion where there is a discrepancy, he said. This approach likely minimizes the risk of falls due to loss of contrast and depth perception, he added. When counseling patients preoperatively, Dr. Chang doesn't mention every possible com- plication that can occur because he doesn't want to overload the patient. Other than a discussion of positive dysphotopsias with patients elect- ing presbyopia correction, "the six things that I point out to all cataract patients are swelling, inflammation, retained lens fragment, retinal detachment, bleeding, and infection." He finds that patients will generally adapt to other visual disturbances as long as they're aware that their symptoms are not the manifestation of a surgi- cal or postoperative complication. Deciding when to intervene Dr. Chang said that most patients will know by postop day 1 if they have any of these issues. For those who received presbyopia-correcting lenses, he will see them at week 1 as well. For patients receiving monofocal lenses, Dr. Chang said he generally doesn't see them between eyes; if they do have a complaint, he makes sure the issue is addressed before oper- ating on the second eye. The second eye rarely needs to be postponed. Deciding whether to remove a lens is proba- bly the most difficult management decision with presbyopic lenses, Dr. Chang said. Fortunately, most issues can be resolved with treatment of dry eye, a refractive enhancement, and/ or a YAG laser capsulotomy. He will typically wait several months before proceeding with an exchange. For symptoms of negative dysphotop- sia, Dr. Chang said he would wait at least 6–12 months before considering any surgical inter- vention, which he has never had to do. If surgical intervention does become necessary after cataract surgery because the patient is unhappy, Dr. Basti said it's important not to make decisions on lens exchange in the first months after surgery. Patients need to be given some time, and sometimes they just need to have a better understanding of the situation and explore it before making a big decision to exchange a lens. "I almost never intervene in the first month," he said, adding that 3 months is about the time he thinks the patient needs in order to adapt or at least give it a true attempt. For those with dryness, routine postop drops have usually stopped around this time, he said, and many patients with dysphotopsia will see it resolve after several months as well. For those with problems that still persist, Dr. Basti again stressed that there is the possibil- ity of surgically exchanging the lens. "For someone unhappy with the outcome, convey to them that you will continue to mon- itor and get them to a good place," he said. "Providing that reassurance is key here." continued from page 62

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