Eyeworld

55 Supported by unrestricted educational grants from Alcon Laboratories and Omeros A thorough game plan can help surgeons achieve patient satisfaction B lurred vision is a leading cause of dissatisfaction after implantation of a premium intraocular lens (IOL). One of the most common reasons is residual refractive error, which must be addressed to ensure patient satisfaction. Postoperative enhancement In a study of 550 patients, we found that the enhancement rate was 9.5% after implantation of multifocal IOLs and 6.7% after implantation of accommodating IOLs. 1 Research indicates that post-cataract refractive error typically ranges from –2.0 to +1.0 D. At the 2013 ASCRS•ASOA Symposium & Congress, Steven Schallhorn, MD, reviewed out- comes in nearly 2,500 patients who had bilateral refractive lens exchange with a multifocal IOL. Pa- tients with astigmatism >0.5 D less often reported that they were very satisfied (Figure 1). Residual refractive error leads to poor patient satisfaction, poor vision quality, and poor uncorrect- ed distance visual acuity. Surgeons should aim for less than 0.5 D of astigmatism. Surgical game plan To avoid residual refractive error, I have developed a surgical game plan. We begin with a thorough med- ical history and examine topography and keratometry. At the slit lamp, I look for basement membrane dystrophy, Salzmann's nodules, dry eye, meibomian gland dysfunction, and pterygia; these patients often have astigmatism that will prevent accurate measurements. If we treat based on unreliable measurements, we may induce more astigmatism. To manage expectations, we explain to patients that reactive stability can take a long time. I share that refractive cataract surgery is an art and everyone's eyes are not typ- ical. I spend extra time on patients who had previous refractive surgery or have an axial length that is out of the typical range, which might affect IOL power calculations. I inform patients if they will need a staged procedure, as with implantation of a multifocal IOL followed by laser vision correction. It's best to address astigmatism during cataract surgery (Figure 2). Limbal relaxing incisions are effec- tive for less than 1.5 D astigmatism. Toric IOLs are good for patients with higher levels of astigmatism who want good corrected distance vision or monovision. We also discuss planned postoperative laser vision correction for high levels of astigma- tism after implantation of multifocal IOLs. In addition, we plan the inci- sion location and take into account our surgically induced astigmatism. Intraoperative aberrometry can also help refine IOL choices. I explain that patients may need postoperative enhancements and typically use laser vision correc- tion for small myopic or hyperopic surprises as long as the cornea is normal. For larger errors, especially hyperopic errors, a piggyback IOL or IOL exchange is a good option. Conclusion To achieve highest patient satisfac- tion, we need to minimize residual refractive error and use the right tool for the right situation. Patient education on the art of refractive cataract surgery is also key. Reference 1. Legault et al. In press. Dr. Gupta is assistant professor of ophthalmology, cornea and refractive surgery, Duke University Eye Center, Steps to minimize residual refractive error by Preeya K. Gupta, MD " Residual refractive error leads to poor patient satisfaction, poor vision quality, and poor uncorrected distance visual acuity. " Preeya K. Gupta, MD Figure 1. After bilateral refractive lens exchange with multifocal IOLs, patients with residual astigmatism >0.5 D less often reported that they were very satisfied. Source: Adapted from slide provided by Steven Schallhorn, MD Postop cylinder vs. very satisfied response Increasing astigmatism = less satisfied patients 80% 60% 40% 20% 0% 73.2% 69.2% 66.9% 58.6% 47.1% 0.0 0.5 1.0 1.5 >1.5 % very satisfied Postop cylinder and clinical medical director of the Duke Eye Center at Page Road in Durham, N.C. She can be contacted at preeya.gupta@duke.edu. Figure 2. Surgical plan to reduce postoperative residual refractive error Source: Preeya K. Gupta, MD Surgical planning • Manage astigmatism (at the time of phaco if possible) – Limbal relaxing incisions (LRI): <1.5 D astigmatism – Toric IOL: >1.5 D astigmatism – Planned postop laser vision correction: for higher levels of astigmatism w/ MF IOL • Think about incision location and SIA • Intraoperative aberrometry is helpful • Residual refractive error – Hyperopic surprise: piggyback IOL or IOL exchange – Myopic surprise: laser vision correction

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