Eyeworld

DECEMBER 2023 | EYEWORLD | 51 R LESSONS LEARNED Relevant disclosures Ayres: Alcon, Bausch + Lomb, Carl Zeiss Meditec Marcos: Co-inventor in patents for anterior segment OCT quan- tification, crystalline lens shape measurement, and estimated lens position from OCT Contact Ayres: BAyres@oppdoctors.com Marcos: smarcos2@UR.Rochester.edu technique, the common one being the Yamane technique or some other form of scleral-fixated IOL. The decentration and tilt are still a prob- lem, and we're placing a lens in the absence of capsular support, and there is not a device or IOL that is specifically made for and designed for non-capsular placement," Dr. Ayres said. "We do all sorts of measurements preoperatively and in the operating room, trying to pick the best technique for that patient. At the end of those surgeries, sometimes you look through the microscope, and even with all the measuring, it still looks a little decentered or tilted, and the repair for that can be difficult." In addition, Dr. Ayres said, all the tech- niques used are technically off label. "We have very good techniques, but they're less accurate when it comes to biometry, and it's easier to get decentration and tilt." Patients are already worried about their vision and know they have a complex ocular problem. The fear and frustra- tion level escalates when in some cases patients need to return due to decentration of the im- plant. Proper counseling and a good doctor-pa- tient relationship is required to maintain trust in these situations. In addition, it's your responsibility to man- age both the patient's condition and help the referring physician manage their relationship, Dr. Ayres said. Many times you're starting out with a frustrated patient, so it's important to try to and improve the patient's outcome and inform them that there is no cookbook recipe for managing complex problems. Even the best surgical solutions may have complications and frustrations. Decentration problems can occur both immediately after surgery or down the line, Dr. Ayres said. He gets calls from doctors during surgery or postop day 1 trying to get the patient a follow-up visit to manage the situation. There are also late dislocations, where the surgery 20 years ago was fine and now there's a zonulopa- thy (maybe the patient had a vitrectomy or has pseudoexfoliation), and the current lens is dislo- cating or tilted. In these cases, we're either try- ing to reposition the existing lens or exchange it for a new one, Dr. Ayres said, which would have to be an anterior chamber lens or an IOL fixated to the sclera, and you run into the same chal- lenges trying to ensure the new lens is properly centered without tilt. Kevin M. Miller, MD, Cataract Editorial Board member, shared a lesson he has learned to "level up": I have increasingly come to appreciate a facet of human behavior that is on full display before and after surgery, especially cataract and refractive surgery. It is that the patient's frame of reference changes after surgery. What would have been a 1 or 2 complaint on a 0–10 scale before surgery becomes an 8 or 9 after surgery. People quickly forget how badly they had it before surgery, and the little things that didn't bother them all that much before surgery suddenly become "big problems" after surgery. Surveys are where you see this behavior on display the most. I have been involved in multiple artificial iris device trials. We always rate photo- sensitivity, glare, halos, etc., before and after surgery. There is no question that iris devices help reduce all these symptoms. Someone may state their symptoms are a 7 out of 10 before surgery and a 6 out of 10 after surgery. How can that be? I remind them: "You said your symptoms were a 7 out of 10 before surgery, and now they are a 6 out of 10. So the surgery and iris device didn't help you that much, correct?" The patient will say, "No, I am much better off now. I'm so happy I had the surgery!" Then I ask, "If you were a 7 before surgery, what are you now?" The patient will answer, "Maybe a 0 or 1." This frame of reference change happens all the time. In order to get at the truth, we need to remind patients how they rated their symptoms (or how bad their vision was without glasses, how poor their reading vision was, etc.) before surgery. Otherwise, they confuse you by subcon- sciously changing their frame of reference.

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