Eyeworld

60 | EYEWORLD | WINTER 2026 R EFRACTIVE If all known causes for patient dissatis- faction have been addressed or ruled out, Dr. Majmudar said the problem could be adapta- tion to the lens optics itself, which could merit an exchange. "If a patient has not adapted to the IOL by 6 months, I would consider an IOL exchange—of course, it is very easy to attribute the symptoms to posterior capsular opacification (PCO), and perform early YAG capsulotomy," he said. "This, however, complicates intraocular exchange. When a patient presents for another opinion and has not had a capsulotomy, I will ask if the symptoms preceded the onset of the PCO. If they did, I would consider IOL exchange and perform capsulotomy after." Lens choice is important when considering an exchange. "If a patient had a trifocal and is unhappy, even if another trifocal may be 'better' historically, there is no guarantee that the pa- tient will be able to adapt to the new lens," Dr. Majmudar said. "And they may not get to fully experience the new lens until a capsulotomy is performed, which would make a much more complex third procedure possibly necessary. The overwhelming goal should be to make the next procedure their last." Dr. Donaldson said for corneal refractive surgery patients, enhancement options depend on the original procedure performed and other current parameters. Options include a flap-lift LASIK enhancement, PRK, a topography- or wavefront-guided treatment, glasses/contact lenses, or a lens-based surgery if the patient has early lens changes. She emphasized that refrac- tion should be stable, reproducible, and that any proposed correction should meaningfully improve the patient's symptoms. "I would recommend against an enhance- ment when the ocular surface is unstable, the refraction is inconsistent, the cornea is too thin, tomography suggests risk of ectasia, the symp- toms are not improved with refractive correc- tion, or the expected benefit is too small relative to the risk. I am also cautious when the primary complaint reflects higher order aberrations or unrealistic expectations that a conventional enhancement is unlikely to resolve," Dr. Donald- son said. If she has an unhappy cataract patient, Dr. Donaldson first treats any ocular surface disease, confirms postop refraction and IOL position, and rules out PCO, CME, ERM, cor- neal irregularity, and other pathologies. If the refractive error is small, especially if it's resid- ual astigmatism, this can significantly affect presbyopia-correcting IOL performance. Depend- ing on the cause, treatment in this case could be spectacles, a contact lens trial, laser enhance- ment, AK, IOL rotation, or a piggyback lens. If symptoms are severe, monocular, or con- sistently attributable to the IOL's optical design, the possibility of an IOL exchange should be dis- cussed rather than repeatedly telling the patient simply to wait, Dr. Donaldson said, noting that the patient needs to understand the risk of this procedure. "At times, if the patient is experienc- ing positive dysphotopsias (such as glare and halos), but they are happy with their reading ability, I will encourage them to proceed with the second eye and use an EDOF or advanced monofocal technology to optimize the distance vision without the loss of near vision. On a rare occasion, I have had a patient who was unhap- py after their lens exchange due to the loss of near, so I would advise preoperatively placing a –3 lens over the eye to cancel the near, to demonstrate the loss they will have with re- moval of the multifocal lens. In contrast, I have never had to remove a lens due to inadequate near vision. Most lens exchanges are generally performed due to vision quality issues (dyspho- topsias) or wrong lens placement." The exam looks perfect but … Dr. Wiley said when acuity is genuinely good and the workup clean, but the patient still insists something is wrong, he doesn't automat- ically turn toward surgery as a solution. "I lay out what is available: glasses, contacts, a surgi- cal enhancement, or simply time. Patients are often relieved to hear that surgery is not their only option and further relieved to hear they do not have to decide today," Dr. Wiley said. "The risk of a second procedure is not necessarily higher than the first, but the benefit available to reclaim may be smaller than it was original- ly, so that ratio may not be as favorable. Once patients understand that, some of them choose to wait, and some never come back to it at all." There are also times when Dr. Wiley said he cannot get a patient where they want to go. "In those cases, I would rather offer a refund on the original surgery than push a low-probability enhancement," he said. "It is not the outcome anyone wants, but it is more honest than oper- ating on a case where I think the risk of making things worse is roughly equal to the chance of making them better." Dr. Majmudar said the patient who is un- happy despite everything looking "right" is one continued from page 59

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