Eyeworld

EW FEATURE 42 by Ellen Stodola EyeWorld Staff Writer Managing multifocal IOL dysphotopsia Dysphotopsias can be a potential problem after surgery, especially with multifocal IOLs O ne issue for patients receiving multifocal IOL implants is the potential for dysphotopsias, which can be bothersome and sometimes affect vision. Richard Tipperman, MD, Wills Eye Hospital, Philadelphia; John Berdahl, MD, Vance Thompson Vision, Sioux Falls, S.D.; Audrey Talley Rostov, MD, cornea, cataract, and refractive surgeon and partner, Northwest Eye Surgeons, Seattle; and Douglas Katsev, MD, Sansum Clinic, Santa Barbara, Calif., commented on dysphotopsias and how to address them in multifocal IOL patients. Characterizing dysphotopsias "One of the things you want to do is characterize them as positive dys- photopsias or negative dysphotop- sias," Dr. Berdahl said. "Positive dysphotopsias are things like glare, halos—something that you see. A negative dysphotopsia is more like a shadow, something you're missing that you feel like you should see." He said that negative dysphotopsias can occur with any type of lens, but positive dysphotopsias are more common with multifocal IOLs. Dr. Talley Rostov said that dysphotopsias can occur with both multifocal and monofocal IOLs. "What's more troublesome are the dysphotopsias of the typical glare and halos, especially with the multifocal IOLs," she said. In a small number of patients, these can be so disabling that the physician needs to do a lens exchange. Typically, dysphotopsias from multifocal IOLs are circles or rings around light, Dr. Tipperman said. It is important when evaluating patients to get a clear description of what they are seeing. He said patients oftentimes come in with pictures or drawings to illustrate. "Until you can understand it and categorize it, you can't even begin to treat it," he said. Causes Dr. Katsev said dysphotopsias are light rays that are altered to create an image that falls incorrectly on the retina, and this alteration causes visual complaints in some patients. "They are often caused by the edge of the lens, imperfections in the lens, as well as the diffractive or refractive aspect of the multifocal lens," he said. "As for the premium IOLs, a zonal refractive lens will result in the most complaints, espe- cially early in the recovery process." "Dysphotopsias may be perma- nent but always soften with time," Dr. Katsev said. "Most often they decrease to a very tolerable level and may even go away." Dr. Berdahl said that when using a multifocal IOL, it's impor- tant for the optical system to be pris- tine. "A multifocal IOL splits light and therefore decreases contrast sen- sitivity," he said. "Anytime there is a change in a structure at the interface then there's an opportunity for light to be scattered. Multifocal IOLs purposely have changes in them, the rings that are on the IOLs, and when the light hits, it can be scat- tered, leading to glare or halos. So part of it is the IOL itself," he said. "The second part of it is that light is traveling through a more complex optical system in general." There- fore, if there is some light scatter from an irregular cornea, anterior basement membrane dystrophy, or another condition, this light scatter can reach an intolerable point when paired with a multifocal IOL. "Part of it is choosing the right candidate for a multifocal IOL at the onset," Dr. Talley Rostov said. It's important to ask about the patient's occupation. If the patient will be doing a lot of night driving, he or she might not be the best candidate for a multifocal IOL. It's important to look for uncorrected astigmatism preoperatively as well as any refractive error because they could contribute to dysphotopsias. "The other thing to look for is any dry eye. Make sure that the ocular surface is healthy because the first thing that we get to is the tear layer when we're looking at how light is refracted by the eye, so any ocular surface disease can certainly be problematic for the patient. If there is ocular surface disease, that needs to be adequately treated because it can either change the refraction and/or cause some dys- photopsia," Dr. Talley Rostov said. Counseling patients Dr. Berdahl explains to his patients that multifocal IOLs are the best technology to make them spectacle Pseudophakic dysphotopsia April 2014 AT A GLANCE • Dysphotopsias can occur with all types of IOLs but may be more common with multifocals. • Many adapt to dysphotopsias, but in severe cases, a lens exchange may need to be performed. • Choosing the right candidate for a multifocal at the onset is important. Patients may complain of an arc image, usually in one quadrant, that bothers them. It is usually described after many of the square-edge optic lenses are placed in the bag. The image is depicted by the drawing of the light rays hitting the square edge of the optic. Source: Doug Katsev, MD Treating continued from page 40 References 1. Davison JA. Positive and negative dysphotopsias in patients with acrylic intraocular lenses. J Cataract Refract Surg. 2000;26:1346-1355. 2. Holladay JT, Zhao H, Reisin CR. Negative dysphotopsias: The enigmatic penumbra. J Cataract Refract Surg. 2012;38:1251-1265. 3. Folden DV. Neodymium:YAG laser anterior capsulectomy: Surgical option in the manage- ment of negative dysphotopsia. J Cataract Refract Surg. 2013;39:1110-1115. 4. Cooke DL, Kasko S, Platt LO. Resolution of negative dysphotopsia after laser anterior capsulotomy. J Cataract Refract Surg. 2013; 39:1107-1109. 5. Masket S, Fram N. Pseudophakic negative dysphotopsia: Surgical management and new theory of etiology. J Cataract Refract Surg. 2011;37:1199-1207. Editors' note: Dr. Holladay has financial interests with the Holladay IOL Consultant, Abbott Medical Optics (Santa Ana, Calif.), and WaveTec Vision (Aliso Viejo, Calif.). Dr. Masket designed the Masket Anti-Dysphotopic IOL mentioned in the article. He has financial interests with Alcon (Fort Worth, Texas). The other physicians interviewed have no financial interests related to their comments. Contact information Cooke: davidlcooke@gmail.com Davison: jdavison@wolfeclinic.com Folden: foldav@gmail.com Holladay: docholladay@docholladay.com Masket: avcmasket@aol.com

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