Eyeworld

46 | EYEWORLD | SUMMER 2024 R EFRACTIVE YES CONNECT potential glare. If they are happy with it, we can do the same for the dominant eye, but if they want less glare in the dominant eye, we can place a monofocal." When to exchange Dr. Wang said this may depend on if you're the primary surgeon or if the patient was referred to you. If you are the primary surgeon or had the patient referred soon after the initial sur- gery, Dr. Wang said she may be more likely to offer an exchange on the early side. If the problem is a large refractive sur- prise, you want to exchange sooner rather than later, she said, but if it's dysphotopsia, she will encourage them to wait at least 3 months. But you have to judge patients individually. If the patient has complaints immediately after sur- gery, she's careful not to do YAG capsulotomy, keeping in mind that exchange is a possibility. In cases of UGH syndrome, Dr. Chen will exchange the IOL as quickly as possible to decrease further intraocular inflammation. For vision quality issues and dysphotopsias, she monitors for at least 3–6 months to assess for symptom improvement prior to exchanging. "I also carefully evaluate the ocular surface to en- sure that it is optimized," she said. "In cases of refractive surprises, I monitor at least 3 months to ensure stability of refraction given it takes time for the IOL to settle into its final effective lens position in the capsular bag." Dr. Chen also describes to the patient the potential reasons as to why they may be having visual symptoms and addresses other possible etiologies such as surface dryness or irregulari- ties. "Once all else is optimized, we can proceed with IOL exchange if the IOL itself is the most likely reason for vision problems," she said. "I also emphasize that sometimes certain 'brains,' rather than the person, do not 'like' certain IOLs." Techniques The technique used for IOL exchange depends on the lens that was placed, Dr. Wang said. It's important to know what lens is in the eye. Dr. Chen said, "In cases of refractive surpris- es, if I know the initial IOL that was placed, this Tips for IOL exchange W hen it comes to doing an IOL exchange, there are a variety of factors involved in why the patient may be unhappy and how to proceed. Yvonne Wang, MD, and Allison Chen, MD, discussed scenarios where an IOL exchange may be necessary and techniques to perform it. Common scenarios Dr. Chen said that the most common reasons patients are referred to her for an IOL exchange are poor quality vision with multifocal or EDOF IOLs, UGH syndrome, persistent positive or negative dysphotopsias, or unexpected refrac- tive outcomes. Positive dysphotopsias usually occur due to diffractive optics, and poor quality of vision can occur with diffractive optics or non-diffractive EDOF IOLs. Dr. Wang said she is also most commonly referred patients for IOL exchanges when the patient is unhappy with a multifocal lens due to the dysphotopsias. They end up seeing much more glare or it's not the quality of vision they want, so you could exchange that lens for a monofocal lens. She has also encountered a few scenarios where it was necessary to exchange a monofocal to a different type of monofocal because of dysphotopsias. This typically requires switching to one with a lower index of refrac- tion. "It is important to discuss the risk of glare and halos when consenting patients for multifo- cal IOLs," she said. Another scenario, according to Dr. Wang, is when a patient is unhappy with their refractive outcome. This could mean that they ended up more hyperopic or myopic than expected or they wanted to be corrected for distance vision with a monofocal lens but are then unhappy with the loss of near vision. "In these scenarios, I would first offer non-surgical options such as glasses or contact lens correction. If they do not accept that, laser correction would be the next step. However, not all patients are candidates for laser correction or some strongly prefer a lens exchange." Dr. Chen added, "If a patient is very moti- vated for a trifocal IOL to decrease spectacle de- pendence, I'll often first put it in the non-dom- inant eye to see if they are able to tolerate the We are living in an age where we can deliver some of the most precise refractive results to patients to help meet their expectations and lifestyle needs. Yet the one thing we cannot do is predict with absolute certainty which patients will not be completely satisfied with their re- sults or adapt flawlessly to new lens technologies. As a cataract surgeon, it is important to be comfortable manag- ing patients in these situations. In this issue's YES Connect column, we explore the ins and outs of IOL exchange. The initial steps a surgeon takes in diagnosis and communication can set them up for success. Allison Chen, MD, and Yvonne Wang, MD, are both cornea and refractive specialists who perform IOL exchanges for a multitude of rea- sons. Here they discuss some vital tips for every cataract surgeon to be familiar with. IOL exchanges can be a very rewarding experience, both for the surgeon and the patient. I'm excit- ed to share the expert advice of these two phenomenal surgeons with the YES community as we strive to meet the needs of our patients. —Masih Ahmed, MD, YES Connect Editor

• Blank Page
• Blank Page (1)