Eyeworld

EW NEWS & OPINION 24 September 2017 Presentation spotlight by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer application like MDbackline, you can reach out to all post-surgical patients, but especially the unhappy ones, and get their feedback. Every patient in our office who undergoes cataract surgery is contacted by email a month after surgery with a questionnaire that explores their surgical outcome and rate of satisfac- tion. Fortunately, most patients are happy, and for those who aren't we want to know about it and do what it takes to get their refractive error improved. This software allows you to survey your patients, find out if they are unhappy, and address the problem. Only through feedback and being proactive will you get patients to that state of bliss where they are going to be telling their friends about your practice and the great toric lens they got." Dr. Hovanesian thinks that pa- tient feedback is crucial, as surgeons may not be aware of patient dissat- isfaction. "It is hard to refine results without knowing what the results are. Our goals as surgeons include excellent visual acuity, patient satis- faction, and the reduction or elim- ination of astigmatic error, which are all severely impacted by residual error that needs to be promptly re- duced or eliminated," he said. EW Reference 1. Hovanesian J. Satisfaction and spectacle independence with accommodating IOLs versus multifocal IOLs 2 years after surgery. First presented at the 2016 ASCRS•ASOA Symposium & Congress. Editors' note: Dr. Hovanesian is founder of MDbackline. Contact information Hovanesian: drhovanesian@harvardeye.com might be best handled with a lens exchange. Cylindrical error can be fixed by lens rotation, but not for larger errors, which require either PRK or lens exchange. He recommended the website astigmatismfix.com, a toric results analyzer, as an extremely useful tool for backup, in the management of post-surgical residual error. The website helps cataract and refractive surgeons to determine if a previous- ly placed toric IOL is ideally aligned. It compares the current location of the toric IOL to the patient's current manifest refraction, and can assess if rotating the IOL would decrease residual astigmatism. It also deter- mines the amount of rotation nec- essary and calculates the expected residual refraction. He explained that rotating an IOL within the first few months after surgery is relatively easy, as IOLs do not tend to fixate right away. He occasionally needs to free up IOL haptics, depending on the IOL type. "You will never have to rotate the Trulign lens [Bausch + Lomb, Bridge- water, New Jersey] because it has phenomenal rotational stability. To rotate, we use balanced salt solution to inflate the bag and sometimes simply a cannula to move the lens into place. Sometimes it is that easy, but we have to be careful about the zonules so we don't stretch them too much," he said. "PRK and LASIK are most effec- tive for smaller errors, while IOL ex- changes should only be considered for larger errors, to justify the risk of reoperating. Mostly, however, I rec- ommend not waiting for patients to bring up the topic. Find out what's wrong before patients come to you," Dr. Hovanesian. "Using a software satisfied. Our poll showed 81% 'very satisfied' without glasses, while only 63% were 'very satisfied' when they needed glasses for any activity (P<.01). That is a hard one to deliv- er—no glasses ever. But it is what is expected of surgery and therefore important that we try to achieve this with every tool we have," he said. He explained that with toric IOLs, a 1-degree lens rotation result- ed in a 3.3% decrease in the toric effect, making a 10-degree rotation with a corresponding 33% decrease in toric effect unacceptable. A 30-degree rotation meant a complete loss of toric effect, and more than 30-degree IOL rotation was equal to inducing new astigmatism. The same was true for misalignments, with even 5 degrees of misalignment responsible for tilting and distorting the visual image beyond any accept- able limit. Potential causes of postopera- tive residual astigmatism include: the wrong location (poor axis, IOL rotated, or poor IOL placement), the wrong lens choice (poor power measurement, surprising surgically induced astigmatism and/or posteri- or cylinder), or compounding factors (most commonly ocular surface dis- ease). Ocular surface disease seems to be recognized more and more as a factor affecting cataract surgical outcomes using toric IOLs. "Ocular surface disease is the elephant in the room. The inci- dence of dry eye among our cataract patients is 80%. Most of our patients have ocular surface disease, and it can affect the outcomes of surgery," Dr. Hovanesian said. Enhancement indications When the sum of the spherical and cylindrical error is >0.5 D, Dr. Hovanesian considers performing enhancement. If the cylinder falls outside of the 0.5 D range, pa- tient satisfaction is likely to suffer. According to Dr. Hovanesian, the best way to manage refractive error depends on the type of error you are dealing with. Smaller spherical errors are best corrected with the use of a piggyback lens, PRK, or LASIK, while larger spherical errors Guidelines to help manage postop outcomes and meet patients' expectations T he goal of any ophthal- mic surgery is to provide the best possible vision. Carefully calculated target refraction is easily thrown off by residual refractive error, leaving some patients less than satisfied. High patient satisfaction was strongly correlated with residual astigmatism, according to the out- comes of a survey discussed at the 2017 ASCRS•ASOA Symposium & Congress that included 117 patients who received either multifocal or accommodating IOLs. 1 With many of today's patients demanding spectacle-free vision, surgeons need to understand their options and pool their resources to best reduce residual error. Expectation of no glasses "According to a survey we con- ducted, 34% of our patients feared needing glasses or having blurry vision," said John Hovanesian, MD, Harvard Eye Associates, Laguna Hills, California, in a presentation he gave at the 2017 ASCRS•ASOA Symposium & Congress. "These re- sults came from a typical cataract pa- tient population. People know from their friends that cataract surgery is safe, but what they are looking for is excellent vision. That's what leads to patient satisfaction: excellent vision. This is what we are in the business of. When our patients are happy, we have done our job. We achieve this through reducing refractive error." Dr. Hovanesian's survey showed that 56% of cataract patients were extremely satisfied with their postoperative visual outcomes with residual cylinder <0.75 D, while 80% reported being extremely satisfied with a postoperative cylinder <0.75 D (P<.02). "A patient's satisfaction increases with decreasing astigmatic error, and although studies have shown patient satisfaction with <0.75 D residual astigmatism, I think the cutoff point is 0.5 D. Likewise, when patients can function entire- ly without glasses, they are very Toric IOLs: When do we enhance? " When our patients are happy, we have done our job. We achieve this through reducing refractive error. " —John Hovanesian, MD

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