Eyeworld

EW NEWS & OPINION 26 Case presentation A 51-year-old patient was referred in because he'd had cataract surgery 1 year earlier with a ReSTOR multifo- cal implant (D1 model, Alcon, Fort Worth, Texas) placed in his domi- nant left eye and he wasn't happy with it. He felt his vision was worse than in the other eye, which had a moderate nuclear sclerosis/cortical cataract, and that he had less than acceptable vision for both distance and near as well as glare at night. His surgeon had waited 1 year for "cortical adaptation," and after the patient noticed no real improve- ment, he was referred to me for eval- uation and treatment. The referring surgeon was perplexed as to the pa- tient's dissatisfaction with the vision in this eye even with his manifest re- fraction in place because all the tests done at his office were normal and the implant was perfectly centered. When I examined the patient his vision was 20/30+1 in the phakic OD eye with a correction of –0.75- 0.5X65. His pseudophakic OS (the eye with the multifocal implant) was 20/25-1 with a correction of +0.25- 1.25X112. Subjectively, however, he felt the vision was not as good in the left eye (the multifocal psuedopha- kic eye) as the other eye with the moderate cataract. I refracted both eyes and put this refraction in the phoropter in front of him. I then placed 3 diopters base up in front of his right eye and 3 diopters base down in front of the left to create diplopia. The patient was unaware of which image, the upper one or the lower one, was from which eye; however, he consistently picked the image from the phakic right eye as the sharper and clearer one even though he could read a bit further down the chart with the left eye. I see many patients on referral for unhappy out- comes from cataract surgery, and often patients will say that they saw worse in the operated eye, perhaps because they are disappointed or even angry about their surgery. Using this prism-induced diplopia test I can mask patients so they don't know which image is from which eye and determine how the images from the two eyes compare. Often patients prefer the operated eye under these conditions, but in this case the patient's responses were October 2011 by Steven G. Safran, M.D. A multifocal mystery Figure 2 Source: Steven G. Safran, M.D. Figure 1 Source: Steven G. Safran, M.D. consistent with his complaint. This patient was clearly having a problem with image clarity from his left eye relative to the right. The patient's testing did not readily reveal the source of his prob- lems. He had no RAPD, and VF test- ing was normal. OCT of the optic nerve and macula were unremark- able. Corneal topography, while not perfect, was not consistent with his complaints (Figure 1). Specular mi- croscopy did not reveal the source of his problems (Figure 2). He had no ocular surface staining with lis- samine green or fluorescein. His im- plant was well centered with a 360-degree rhexis overlap of the optic, no evidence of tilt, and al- though there were some very slight posterior capsule changes, I did not feel these were the source of his problems (Figure 3). Roundtable discussion I presented the information gath- ered to my panel of experts: Jeff Whitman, M.D., Dallas, Texas, Lisa Arbisser, M.D., Iowa and Illinois Quad Cities, Joe Sokol, M.D., Shel- ton, Conn., Brad Oren, M.D., Palm Beach, Fla., Brian Kim, M.D., Dal- ton, Ga., Keith Baratz, M.D., Rochester, Minn., Jim Lewis, M.D., Philadelphia, Penn., Jeff Horn, M.D., Nashville, Tenn., and Ed He- daya, M.D., Lakewood, N.J., to get some thoughts on where to go from here. We had a "grand rounds" type of discussion via the internet, and some felt that 1 year was a long enough trial of this patient's neu- roadaptation to consider this a "multifocal failure" and to justify consideration of an IOL exchange. Here are my colleagues' re- sponses: "In summary, this patient had 'perfect' surgery with a well-centered IOL, no macular disease, no ocular surface disease, no endothelial dys- function, no HVF defects, no color defects, no RAPD, minimal PC changes, and was never happy with the VA. It seems this patient is one of those ReSTOR patients who could never and will never tolerate the multifocality. I would not YAG the PC since the patient's sxs occurred immediately after surgery and thus the PCO is unlikely the cause for the unhappy VA. I think the patient needs an IOL exchange, and I would choose a Crystalens (Bausch & Lomb, Rochester, N.Y.) if he wants some presby-correction. If he doesn't want presby-correction, I would choose a monofocal aspheric IOL due to the persistent glare and night time sxs." Brian Kim, M.D. T his month, EyeWorld introduces a new column devoted to case-based learning, which we are calling "Anterior segment grand rounds." Steve Safran is a cornea fellowship-trained anterior segment surgeon practicing in Lawrenceville, N.J. Steve has a busy surgi- cal referral practice, and I have always been impressed with his surgical insights and thoughtful analytical approach. For this reason, I have asked him to lead our grand rounds sessions in which he will ask other clinicians how they would handle a difficult case from his own practice. We invite EyeWorld readers to submit an interesting or perplexing case of their own to Steve, much as they might present that case to colleagues at their local grand rounds. Dis- cussing interesting cases is a great way to share ideas and experiences, and we hope you'll enjoy learning from these practical case-based discussions. David F. Chang, M.D., chief medical editor Anterior segment grand rounds Steven G. Safran, M.D. If you have a case that you would like to send to Dr. Safran for consideration as a "case of the month" for the ASGR column please contact him at safran12@comcast.net

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