Eyeworld

APRIL 2023 | EYEWORLD | 61 C References 1. Venkateswaran N, et al. Com- parison of patient perceptions of first- and second-eye cataract surgeries. J Cataract Refract Surg. 2021;47:819–820. 2. Adatia FA, et al. Documenting the subjective patient experience of first versus second cataract surgery. J Cataract Refract Surg. 2015;41:116–121. Relevant disclosures Braga-Mele: None Finklea: None surgery is done, and they have a 20/20 first eye, anything you give them for the first 24–48 hours isn't going to be better than that, which leads them to think something went wrong with the second eye. Dr. Braga-Mele said she usually books the eyes a week or two apart. She also lets pa- tients know preoperatively that they'll have a 24- to 48-hour recovery with their vision. She stresses that each eye will heal differently. Dr. Braga-Mele said she likes to use a quote she learned from Dee Stephenson, MD: "Your eyes are like sisters, but they're not twins." She said patients understand that right away. "Each eye will heal differently and react differently to the procedure. The minute you say it's normal, that alleviates a lot of the tension for the patient," she said. She added, "Most patients forget what I told them, so you have to reiterate right after the second eye is done." When Dr. Braga-Mele sees patients the morning after surgery, she'll imme- diately address this. "I'll say that it's completely normal for the second eye to seem like it took longer." Dr. Braga-Mele also does bilateral same- day cataract surgery, though not on all of her patients, and she plans to start a study looking at whether the second eye has any issues with this. In her experience, when patients have bilateral same-day cataract surgery, they don't compare eyes as much and treat it more like one procedure. No matter the timing between the proce- dures, Dr. Braga-Mele stressed the importance of educating the patient preoperatively, as well as right after the second eye on day 1 postop. "Patients will sometimes think they need to see immediately after surgery," Dr. Braga-Mele said. "I always say, 'You don't have a hip replacement and expect to run a marathon the next day, so you can't have eye surgery and expect to see perfectly the next day.'" She sets the expectation of 1–3 months. Most importantly, Dr. Braga-Mele said you need to under promise and over deliver, and "you definitely have to do that more for the sec- ond eye than the first eye." Patients are general- ly more at ease going into the second procedure and expect vision to recover quickly while also comparing it to the first eye. The comparison is the problem, so that's why patient education is so important. expectations are crucial and vary from patient to patient. This preop assessment is even more important than the surgery itself. The successful 'neuroadaptation' that happens postop begins with proper patient selection preop." Beyond that, Dr. Riaz said that even with proper preoperative assessment, there will be a good number of patients who need handhold- ing, reassurance, and observation of symptoms like glare, halos, and vision that's not meeting their expectations postop. If patients are still unhappy at 3 months and they have not had a YAG capsulotomy, he will perform an exchange for a monofocal or Eyhance IOL (Johnson & Johnson Vision). Dr. Riaz said if the postop refraction is consistently myopic or hyperopic, residual refractive error could be to blame. Dr. Tsai said residual refractive error can contribute to complaints like night glare and blur. She said a careful manifest refraction is mandatory. "If uncorrected refractive error is the cause, giving the patient an accurate refraction should correct the visual complaints," Dr. Tsai said, but the bigger concerns are usually things like irregular corneal astigmatism or higher order aberrations. Dr. Wang shared similar thoughts. "Residual refractive error, especially residual astigmatism, may cause the postop dissatisfaction," Dr. Wang said. "Performance of meticulous manifest refraction may determine if the postop dissatisfaction is caused by residual refraction error." continued from page 59

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