Eyeworld

EW NEWS & OPINION 16 Experts Dr. Masket, clinical professor of ophthalmol- ogy, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles, Dr. Fram, and Dr. Ceran discuss the best ways to treat patients with negative dysphotopsia C linical experience dictates that there are no beneficial medical therapies for the patient with symptomatic negative dysphotopsia (ND), originally noted by James A. Davison, M.D., adjunct associate clinical professor, University of Utah, Salt Lake City, as patients complain of a dark temporal cres- cent, similar to "horse blinders." 1 Fortunately, surgical methods have been devised that have proven useful in reducing visual symptoms of ND. Although ND rarely induces visual disability sufficient to require an operative approach, some pa- tients are disturbed by it and can be very vocal in their complaints. This may be particularly true when pre- mium intraocular lenses (IOLs) have been implanted. Perhaps the most frustrating aspect of this problem for surgeon and patient alike is that ND has only been reported in cases where the IOL (any type may be causal) is well centered within the confines of the capsular bag. To our understanding, ND has never been reported with sulcus-placed PCIOLs or ACIOLs. In our investigation, we found that ND is generated from the over- lap of the anterior capsulorhexis onto the anterior surface of the IOL. 2 Given the latter, and in keeping with our studies, two surgical strate- gies have emerged as beneficial. Failed surgical strategies include bag/bag IOL exchange wherein the original implant is removed and an- other of different material, shape, or edge design is replaced within the capsule bag. This is in keeping with the work of Peter Vamosi, M.D., Ph.D., Budapest, Hungary, and col- leagues. 3 September 2011 by Samuel Masket, M.D., Nicole R. Fram, M.D., and Basak Bostanci Ceran, M.D. Surgical approaches for negative dysphotopsia Figure 1. A Sinskey hook is fed under- neath the anterior capsule following viscodissection in an attempt to free the optic from the capsule Figure 2. The Sinskey hook and blunt spatula are used to elevate the optic edge over the capsule Figure 3. Once the nasal edge has been captured (see arrow), the opposite, temporal edge of the optic is elevated over the anterior capsule edge Figure 4. Optic capture has been completed. The nasal and temporal edges of the implant are anterior to the anterior capsule (note arrows), whereas the haptics remain fully within the capsular bag Source: Basak Bostanci Ceran, M.D. C omplaints related to post-op negative dysphotopsias can be frustrating for both the pa- tient and surgeon. The temporal nega- tive crescentric scotoma occurs infrequently, and in many of these pa- tients it will improve or resolve over several months. However, when it does not improve, these patients can be some of the most demanding and un- happy individuals in a cataract practice. In this month's column, Drs. Masket, Fram, and Ceran present an excellent review of this phenomena, explaining what works and what has not been found to be effective for eliminating these dysphotopsias. The concept that the relationship of the anterior capsu- lorhexis to the IOL optic rather than the relationship of the IOL optic to the pos- terior iris is responsible for these opti- cal aberrations is a new revelation that may help us better treat these dissatis- fied patients. Hopefully, these cases will con- tinue to be rare occurrences in your practice. But when they do show up one day, this article will help you decide on the best surgical option for turning these patients back into happy campers. Richard Hoffman, M.D., techniques editor Successful surgical methods Reverse optic capture (ROC) may be employed in a secondary surgery for symptomatic patients or as a pri- mary prophylactic strategy. In cases of the latter strategy, the method has been applied to the second eye of patients who were significantly symptomatic following routine un- complicated surgery in their first eye. It should be noted, however, that ND symptoms are not necessar- ily bilateral. Secondary ROC, performed for symptomatic patients, may be ap- plied if the anterior capsulotomy is not too small or too thick or rigid from post-op fibrosis. At surgery, the anterior capsule is freed from the underlying optic by gentle blunt and viscodissection. Next, the nasal ante- rior capsule edge is retracted with one Sinskey hook (or similar device) while the optic edge is elevated and the capsule edge allowed to slip under the optic (Figures 1 and 2). This maneuver is repeated 180 de- grees away temporally (Figure 3), leaving the haptics undisturbed in the bag inferiorly and superiorly (Figure 4). (See video.) Should the haptics be oriented horizontally, it would be best to rotate them 90 de- grees, if possible. Primary or prophylactic ROC is performed at the time of initial rePlay online content Or view the video at www.eyeworld.org/replay.php. Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) Slug: techniques_0911 Word count: 1250 Images: 4, Hoffman mug Tools & techniques

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