Eyeworld

44 | EYEWORLD | JULY 2023 ATARACT C by Liz Hillman Editorial Co-Director About the physicians J. Morgan Micheletti, MD Berkeley Eye Center Houston, Texas Samantha Schockman, MD Cincinnati Eye Institute Cincinnati, Ohio Joshua Teichman, MD, MPH Prism Eye Institute University of Toronto Toronto, Canada "If you know it's a miss, and you know there is stability, and you know it's not an unusual situation like post-RK, but for whatever reason you've had a refractive miss, you can ex- change relatively early on," Dr. Micheletti said. "Relatively early I would say is within a month. If they're not improving and they have a docu- mented refractive error that's large, I would go back in pretty quickly." If the patient is off by less than a diopter, the patient is a good candidate, and it isn't a rotational issue with a toric lens, Dr. Micheletti added that he'd consider a LASIK enhancement instead of intraocular surgery due to the risks. Dr. Schockman said when there is a me- chanical or anatomical issue causing compli- cations, the decision to proceed with an IOL exchange is relatively straightforward. "It can be less clear when an IOL exchange is warrant- ed when the patient has visual complaints in an otherwise healthy eye," she said. "When the patient is unhappy with their vision after cataract surgery, the surgeon should first make sure the correct IOL was placed, the IOL is in good position, and the eye is otherwise in good health," Dr. Schockman said. "It is ad- visable to repeat IOL measurements for accura- cy. Any other cause for the patient's visual com- plaints should be ruled out. If there is dry eye, the ocular surface should be optimized. In the case of multifocal IOLs, the surgeon should al- low adequate time for neuroadaptation to occur. Once a stable refraction has been demonstrated, laser vision correction can be considered in the case of a refractive miss. The surgeon should try optimizing the patient's vision prior to deciding on an IOL exchange. If the patient continues to have problematic symptoms despite clinical op- timization, a detailed discussion is warranted to weigh the benefits and risks of IOL exchange." Dr. Teichman said if an exchange is being considered for incorrect IOL power or toricity, he'll proceed once a stable refraction can be obtained. If the exchange is due to intolerance of a presbyopia-correcting IOL, some consider waiting months for neuroadaptation. Dr. Micheletti said if a patient is extremely bothered by severe dysphotopsias due to a diffractive IOL from the day of implantation, "you likely need to intervene sooner rather than later." IOL exchange 101 T here are many motives and methods for IOL exchange. While a rare need, the physicians who spoke with EyeWorld said it's important to be familiar with the indications for ex- change, removal techniques, and considerations for IOL replacement. "Thankfully, the need to perform an IOL exchange is relatively uncom- mon in modern ophthalmology," said Samantha Schockman, MD. Morgan Micheletti, MD, remembers IOL exchanges being portrayed as "a scary, complex, and challenging surgery" when he was a med- ical student. While these cases aren't routine, he said that ophthalmologists are now more comfortable with the surgery. Joshua Teichman, MD, said the decision to exchange is a joint one between the surgeon and patient. "A surgeon who performs more IOL exchanges will have a low complication rate and likely offer this earlier than a surgeon who does not," Dr. Teichman said. "It is important that those who implant IOLs more prone to dissat- isfaction be comfortable with IOL exchange. When a patient is unhappy from something that is clearly attributable to the IOL and exchange has a reasonable chance of improving this, I think an exchange is warranted. It is important that other issues be ruled out first. If patients are unhappy with presbyopia-correcting IOLs immediately postoperatively, one can generally assume that this is not from posterior capsule opacification, and a YAG capsulotomy should be avoided. IOL exchange in the presence of an open posterior capsule increases the risk and may be surgically more challenging. One should be prepared to perform a vitrectomy in these cases, and if the capsular bag integrity is com- promised, be prepared with a 3-piece IOL for sulcus placement and/or flanged double needle intrascleral haptic fixation (Yamane)." Why exchange and when According to the physicians, there are sever- al reasons for IOL exchange: refractive miss, dysphotopsias, intolerance to presbyopia-cor- recting designs, dislocation/subluxation, IOL defects/damage/opacification, and secondary issues (e.g., corneal edema from AC IOLs, UGH syndrome, etc.).

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