Eyeworld

EW RESIDENTS 98 September 2016 by Megan Law, MD, Kareem Moussa, MD, and Minjy Kang, MD, UCSF residents T echnological advances have revolutionized cataract surgery. Smaller corneal incisions, foldable intra- ocular lenses (IOLs), and high performance phacoemulsifica- tion systems have increased surgi- cal efficiency and provided faster postoperative recovery. Following the introduction of multifocal and accommodative IOLs, an increasing percentage of patients began to seek cataract surgery not only for visual rehabilitation, but also to attain some degree of spectacle indepen- dence. In the new era of refractive cataract surgery, patient expecta- tions for excellent subjective and objective visual outcomes are only expected to increase. Historically, IOL exchange has been performed primarily for vision-threatening complications, such as IOL dislocation, uveitis-glau- coma-hyphema (UGH) syndrome, or pseudophakic bullous keratopathy. Dislocation of in-the-bag IOLs has been the most common indication, but fortunately remains rare after cataract surgery, with a large study demonstrating a rate of less than 1% after 10 years. 1 As technology improves and expectations rise, Visual outcome was evaluated at 1 month by comparing the manifest refraction to the preoperative refrac- tive aim, with consideration of other potential causes of decreased vision unrelated to the IOL exchange pro- cedure. The mean time interval be- tween the date of the initial cata- ract surgery and IOL exchange was varied based on the indication for exchange, but overall was 1,657 days±2,172 days. The most common indications for IOL exchange in the study were dislocation of an in- the-bag PCIOL (n=30 eyes, 27.5%), visual intolerance of a multifocal IOL (n=20 eyes, 18.3%), and UGH syndrome (n=13 eyes, 11.9%). Most of the cases of dislocated IOL were related to pseudoexfoliation (n=11 eyes, 30.6%). The most common ex- planted IOL type was a single-piece acrylic monofocal IOL (n=40 eyes, 36.7%). The most frequently im- planted IOLs were the L or S 122UV (Bausch + Lomb, Bridgewater, New Jersey) (n=28 eyes, 25.7%). The IOL was replaced most often in the capsular bag (43.1%, n=47 eyes). In 78.9% of cases (n=86 eyes), the final visual acuity at the 1-month follow-up was 20/40 or better, with 70% of cases reaching the refractive target within ±0.50 D. There were three cases of intraoperative compli- cations (suprachoroidal hemorrhage, posterior capsular tear, and severe zonular dehiscence). The most com- mon postoperative complication was posterior capsular opacification, followed by cystoid macular edema and high astigmatism. IOL exchange for dislocated IOL had the highest rate of complications (five cases of CME, three cases of zonular weak- ness). Comments The findings of this retrospective chart review provide significant insight on the evolving indications and outcomes of IOL exchange. This study confirms previous literature citing in-the-bag IOL dislocation as the most common reason for IOL exchange. IOL dislocation may be surgically managed either by repositioning or IOL exchange. A retrospective study of 45 cases of late spontaneous in-the-bag IOL dislocation by Lorente et al. showed favorable outcomes with low risk of complications using either reposi- tioning or IOL exchange, but pre- ferred repositioning due to smaller incision size. 4 Overall, Lorente et al. reported statistically significant post- operative improvement of corrected distance visual acuity (CDVA), with CDVA of 20/40 or better in 62.22% of the eyes. The current study by Davies and Pineda also confirms fa- vorable outcomes for IOL exchange in the setting of in-the-bag PCIOL dislocations, reporting visual acuity at 1-month follow-up of 20/40 or better in 78.9%. A significant implication of this study is the high incidence of IOL exchange for dissatisfaction with multifocal lenses. This was the second most common indication for IOL exchange in the study patient population. This finding has not been well established previously, but will likely be a significant and con- tinuing trend given the rising use of multifocal and accommodative IOLs and higher visual expectations of patients postoperatively. Although visual acuity may be excellent in these patients, symptoms such as asthenopia and glare/halos may be intolerable. These were the two most frequently cited reasons among those with dissatisfaction of multi- focal IOLs in Pineda's study. Pineda reports very favorable outcomes in postoperative patient satisfaction Review of "Intraocular lens exchange surgery at a tertiary Indications, complications, and visual outcomes" EyeWorld journal club University of California, San Francisco residents (from left to right): Megan Law, MD, Kareem Moussa, MD, and Minjy Kang, MD Source: University of California, San Francisco What are the most common indications for IOL exchange, and what is the risk? I asked the UCSF residents to review this retrospective, single surgeon study published in the September JCRS issue. –David F. Chang, MD, EyeWorld journal club editor Julie Schallhorn, MD, associate program director, University of California, San Francisco patient dissatisfaction and subopti- mal refractive outcomes are evolving as indications for lens exchange surgery. A recent study found pa- tient dissatisfaction to be the third most common indication for IOL exchange, following IOL disloca- tion and incorrect IOL power. 2 At least one-third of those seeking IOL exchange in this study were intol- erant of glare and halos following multifocal IOL implantation. This is a significant increase from what Jin et al. reported in 2005, where only 7.8% of patients underwent surgery for visual symptoms. 3 Given the changing landscape in cataract surgery, it is important to continuously evaluate our outcomes to allow us to provide meaningful data to our patients. The current study evaluates the etiology and outcomes of IOL exchange at a ter- tiary care center in the current era of both monofocal and multifocal IOL implantation. Study summary The study retrospectively evalu- ated 109 cases of IOL exchange performed by a single physician between January 2010 and Sep- tember 2015. The authors analyzed the most common reasons for IOL exchange, the most common types of IOL removed and implanted, and the most common intraoperative and postoperative complications.

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