Eyeworld

DECEMBER 2023 | EYEWORLD | 35 C LESSONS LEARNED Relevant disclosures Kandavel: Alcon, Bausch + Lomb, Glaukos, Tarsus Nejad: None Rai: Alcon, Bausch Health Contact Kandavel: valleyeyedoctor@gmail.com Nejad: MNejad@mednet.ucla.edu Rai: AmandeepRaiMD@gmail.com include pseudoexfoliation syndrome, previ- ous vitrectomy, and poorly dilating pupils that may predispose to intraoperative floppy iris syndrome. "We know these patients may be at increased risk for intraoperative complications, and allowing the cataract to become hyperma- ture only serves to elevate the complexity of the surgery for the surgeon and the corresponding risk for the patient," Dr. Rai said. "I have been referred patients who previ- ously had complicated surgery elsewhere for their first eye, and their second eye was can- celed and has subsequently progressed to a hy- permature cataract," Dr. Rai continued. "Under- standably, these patients are concerned about proceeding with cataract surgery in their 'good eye,' but they have paradoxically increased the risk for complications by delaying surgery. Of course, when there is a surgical complication, the first priority is to rehabilitate that eye to its visual potential, which is often quite good. Once that is accomplished, the other eye should not be ignored, and the patient should be offered cataract surgery in a reasonable timeframe. A referral to a colleague can help reduce stress for both the patient and ophthalmologist. Another example is a patient who presents with a rapid onset white cataract in one eye and an early posterior subcapsular cataract in the other eye. I would proceed with removing both cataracts as soon as possible instead of allowing the mild posterior subcapsular cataract to rapidly prog- ress into a more complicated surgical case." When deciding when to move forward with cataract surgery, Dr. Kandavel said he will ask patients to clear their schedules for 3–4 weeks after surgery in case anything occurs in the post- op period. "I also tell them on initial consulta- tion that they won't be able to go in the pool or in the water at the beach. I always tell them if they plan to go outside the continental U.S. to take that trip before they have surgery. I gener- ally don't recommend doing one eye, going on vacation, and coming back and doing the other," he said. "I frequently will have a husband and wife come in for a simultaneous consultation, and I always tell them that only one person can have surgery at a time because they need someone to be the driver, and they may need someone to put in drops if that ends up being a problem." If patients decide at the end of the consultation to postpone surgery, Dr. Kandavel said that he advises them that he will repeat testing and the dilated exam 90 days after the consultation. "Patients are highly educated about cata- ract surgery and their lens options even prior to their consultation with me," Dr. Rai said. "They have consulted their friends and the internet to learn about their intraocular lens options, and many patients are seeing cataract surgery as an opportunity to improve their clarity and best corrected vision and their pre-existing refractive error. "Patients who have more advanced cata- racts are very easy to please because the postop- erative difference in best-corrected visual acuity is more appreciable. However, with improved IOLs and biometry, modern cataract surgery allows great predictability with respect to re- ducing refractive error. As a result, patients who have significant pre-existing refractive error also tend to be quite pleased following cataract surgery as they notice a large benefit in their uncorrected distance visual acuity and possibly a presbyopic benefit as well," Dr. Rai said. Rosa Braga-Mele, MD, Cataract Editorial Board member, shared a lesson she has learned to "level up": I have found that when dealing with com- plaints of quality of vision from MFIOL pa- tients, it is important to listen but also show them what their near vision would be like without the MFIOL. I put up –2.50 trial lenses in front of their eyes while having them hold a Jaeger near card. Once they see what their up-close vision would have been like with a monofocal IOL, most will stop complaining about little issues. Also always let your patients know it can take up to 3–6 months for foreign body sen- sation to go away and neuro- adaptation to take place with their new lenses.

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