Eyeworld

56 | EYEWORLD | APRIL 2023 ATARACT C Contact Miller: kmiller@ucla.edu Tipperman: rtipperman@oppdoctors.com a YAG on those patients, you can make things worse because dysphotopsias become worse, and exchanging them becomes a bigger prob- lem," he said. When having a discussion preoperatively with the patient, Dr. Tipperman noted it's im- possible to mention every single problem that can occur. However, for those patients who say they want to have "perfect" vision, Dr. Tipperman will reiterate that "we can only make it so good," and if they're not happy, there are ways to make it better. Dr. Tipperman said he doesn't normally dis- cuss unwanted optical images unless the patient brings them up. Depending on anterior chamber depth, you will see a much more obvious reflection off the IOL than off a natural eye, and Dr. Tipperman said patients often ask about this. Many have heard about this from a friend or relative. The reflection off someone's eye after cataract sur- gery is different, and we can't control it, he said, but if patients are concerned from an appear- ance standpoint, silicone IOLs are an option. Dr. Miller agreed that he doesn't discuss ev- ery problem that can occur with patients. "One of the pieces of the psychology puzzle in com- plication management is that every patient after surgery wants to know why you didn't spend more time talking to them about the complica- tion they experienced," he said. "They don't care about the ones they didn't experience. All they care about is the one they did." Dr. Miller mentions halos around lights for patients getting EDOF and multifocal lenses. He will describe what it looks like. Halos can be bother- some in the first month or two, but patients may stop noticing them after a few months. "When I see patients a year later, virtually no one com- plains of halos, and almost all can drive well at night and see street signs," he said. A pesky problem for ophthalmologists is when a patient comes into the office com- plaining of halos 3–4 months after surgery and there are wrinkles in the posterior capsule. You have to figure out if it's the wrinkles or the lens design that's causing the vision problem, he said, cautioning not to jump immediately to a lens exchange in these situations. Most times, opening the capsule fixes the problem. Dr. Miller mentioned several other problems that he sees after cataract surgery, including EBMD, CME, ptosis, corneal neuralgias, multifo- cal IOLs that are not centered in the pupil, and irregular astigmatism. He called CME "one of those things that haunts cataract surgeons." It happens not infre- quently in diabetics and patients with epiretinal membranes, but sometimes it happens in eyes that are totally normal. "When someone with any lens comes in a month after surgery saying, 'My vision is blurry,' and you look at the anterior segment and everything is clean, then you have to get an OCT or fluorescein angiography to see if there is CME," he said. Dr. Miller noted the importance of docu- menting ptosis prior to surgery. "I can't tell you how many times patients don't see themselves well in the mirror before surgery, and they don't know they have a droopy eyelid or wrinkles on their face. If you don't mention ptosis or wrin- kles before surgery and they discover it after, they will wonder what went wrong," he said. Corneal neuralgias are an under appreciat- ed problem. "The patient comes in saying they have an irritation or foreign body feeling," he said. "You look carefully and everything seems perfectly normal, then they come in again and again complaining of the exact same thing." Patients with this issue often go from doctor to doctor. Sometimes the neuralgias resolve on their own, he said, adding that he usually waits about a year to treat. "I'll have them massage the area where the incision is to see if this helps to get the cut nerve or nerves to stop misbehav- ing. If it doesn't after a year, I'll take them back to the operating room and recut the incision," he said. "I'll recut the incision proximal to the original incision, deeper and wider so I make sure I transect every nerve that went through continued from page 55 Capsule stria are another source of patient frustration after cataract surgery, especially in the presence of a multifocal intraocular lens. Source: Kevin M. Miller, MD

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