Despite surgeons’ continuous efforts to consistently deliver optimal surgical outcomes, visual complaints do arise among patients who have undergone cataract, cornea, refractive, pterygium surgeries.
There are steps each surgical team can take both pre- and postoperatively to reduce the likelihood of facing an unhappy patient.
A thorough preoperative evaluation including meibography, Pentacam, Optos, A-scan, OCT, Endothelial cell count where indicated and taking the time to learn about the patient’s lifestyle is crucial in determining which surgical approach and intraocular implant, in the case of cataract surgery, will most benefit each patient.
It has become very clear in the last few years that the tear film and the meibomian gland status are crucial to determine the quality of vision after any eye procedure. The issue of maximizing the tear film quality is critical in any pre-operative evaluation.
NO. 1 Complaint: Need of EYEGLASSES AFTER CATARACT SURGERY
Despite all the amazing technology available, some patients still need glasses after cataract surgery. This is becoming less of an issue with newer advances in intraocular lens (IOL) technology, such as the PanOptix trifocal. But still, there is a risk depending on one’s risks factors of needing glasses to correct residual astigmatism or refractive error.
Of note, it is always important to ask the patient if they can “blink the vision clear.” I will ask, “are there times that the vision is clear and the way you want it?” If the answer is yes, dry eye and/or meibomian gland disease is usually the culprit and this needs to be addressed as long as the posterior capsule is clear, the nerve and macula are normal on dilated exam, OCT, or/and HRT if needed.
The best way to prevent a long post-cataract-procedure discussion on the need for glasses after the cataract surgery is to address this risk openly with the patient and family members before the procedure. If a patient has had previous refractive surgery, such as LASIK, PRK, RK, it is important to discuss the higher risk of needing glasses or even IOL exchange or another refractive procedure after cataract surgery to help decrease residual refractive error.
A patient’s personalities and lifestyles, and risk factors can help to determine whether they are good candidates for monofocal (ie, one focal plane will be in best focus), multifocal, extended depth of focus (ie, Symfony), or Trifocal PanOptix IOLs.
Currently, the Trifocal PanOptix IOL is not recommended in post LASIK, PRK, RK patients but I know of a surgeon who has implanted this in a post LASIK patient: results still pending. There are no papers out on this yet.
Similarly, Symfony is not recommended in post LASIK, PRK, RKpatients but many surgeons including myself have properly consented patients on the risks and have had very happy patients. The key issue with these patients is looking at the Pentacam’s Holladay formula’s Higher Order Aberrations (HA) value. If the value is negative, these patients will often not do as well as those who have a positive HA value: the closer to zero but positive the better. There are no studies to my knowledge quantifying what is the best HA value for these patients and which patients will love their Symfony IOL and which will hate it. This is the next frontier: to determine who will like which IOL.
All surgeons usually always try to under-promise and over-deliver, but some patients forget the surgeon discussed these risks. Thus it is important to document the conversation and encourage loved ones to be present for this conversation. We have asked patients, particularly if they are alone, if they will consent to being videotaped during the cataract consultation so the patient and family can review the discussion in the future if needed. As we are seeing more patients with dementia, this is a valuable tool we have used with proper consent.
NO. 2 Complaint: DRY EYE Symptoms AFTER REFRACTIVE SURGERY
It is crucial to perform meibography prior to any eye procedure, including a stye/chalazion excision. I recently saw 3 patients who had a stye excision with another 3 different surgeons. Each patient said the eye felt much worse after the procedure to the extent that 2 of them were seeing me to get a second opinion and considering legal action against the primary surgeon.
When I showed them their meibography, I was able to help them understand and see that the reason for their worsening pain was because of meibomian gland atrophy that had been going on for months-years before the acute stye/chalazion that was removed by the first surgeon.
Usually, it takes months to years for grade 3-4 meibomian gland atrophy to develop. A simple stye/chalazion removal had tipped each one over the edge into chronic eye pain.
It is not uncommon for surgeons to hear complaints of dry eye after uneventful cataract or refractive surgery. Usually, this occurs later in the postoperative period– after the patient’s initial enthusiasm about seeing without optical correction (contact lenses or eyeglasses). In order to prevent this downer, preoperative evaluation of the tear film, its stability and meibography must be performed with extra attention.
If the tear break-up time is normal, the surgery may be scheduled; however, if it is not acceptable, the patient should be diagnosed with dry eye and the surgery postponed until the condition is remedied. It is true though that the tear film remains unstable despite FDA approved treatments and the cataract surgery has to be performed. At Visionary, we use Autologous Serum and PRP drops to improve the tear film and resolve any keratitis prior to the A-scan and cataract surgery when possible if Xiidra & Restasis did not help or was not tolerated. Thus it is important to show patients their meibography and explain the implications of scarred or missing meibomian glands.
All signs of blepharitis and meibomitis must be addressed and treated before and after surgery. Particularly after LASIK, MGD, blepharitis, meibomitis, ocular rosacea need to be addressed and treated as excessive meibomian secretions are associated with greater risk for diffuse lamellar keratitis.
I have posted many times about all the treatments for Dry Eye in the world. Please see this link for my latest STEP LADDER Sheet on how I treat dry eye starting at #1 with least difficult/expensive/painless options.
NO. 3: DYSPHOTOPSIAS INCLUDING GLARE, DARK SHADOWS, HALOS
Complaints of dysphotopsias are common after cataract surgery. There are 2 types:
Positive: seeing a sensation of light, flash, or streak of light
Negative: seeing a dark shadow like a crescent around the IOL/implant’s edge.
These symptoms occur more commonly with squared-edge IOLs. Newer IOL designs have decreased this risk but it can still happen.
What to do:
1. Ask if blinking makes it better or using artificial tears. Dry eye can make many visual symptoms worse. So if the patient can blink it away, it is a tear film and ocular surface issue that needs to be addressed with the options below.
2. If the symptoms cannot be blinked-away: Look at IOL centration: Is the optic centered in relation on the pupil? Is the IOL centered in the capsular bag or sulcus.
3. If the IOL is centered, the surgery has been well performed and symptoms usually will become less distressing over time and usually disappear in a few months without any further need for treatment.
4. If the patient is very unhappy, an alpha-agonist drop, brimonidine tartrate (Alphagan; Allergan, Inc.) can reduce pupil size, which, in most cases, reduces the symptoms. Rarely pilocarpine 1% drop every other day or every week can help but we explain to patient the rare risk of a retinal detachment if pilocarpine is used chronically. Thus this is rarely given and patients are encouraged if given to use rarely.
5. If the IOL is not well centered, the IOL may been to be repositioned in the operative room depending upon the severity of the symptoms. This is rarely needed.
6. If IOL repositioning does not help or patient continues to have terrible symptoms, the IOL is explanted and a different IOL is placed. It can be that a patient with a multifocal IOL or even Symfony (very rare) cannot tolerate the dysphotopsias and wants to have it explanted and have a monofocal. Most patients who have this done usually are happy
NO. 4: PHOTOPHOBIA
Photophobia is common after laser iridotomy, cataract and refractive surgeries, particularly among patients with light-colored (blue–green) irides. It usually starts during the early weeks after the procedure. Most cases decrease within weeks or months. Sunglasses are always needed after surgery when the patient is outside or exposed to bright light. Rarely, miotic drops (pilocarpine 2%) can be used temporarily during the morning to decrease pupil size.
After a Laser Iridotomy, the permanent hole in the iris can cause light sensitivity. This resolves in more than 99% of patients. Rarely does this need to be addressed with a corneal tattoo or aniridia IOL (very rare).
Also rare after cataract surgery is a chaffing of the iris from iris prolapse during the cataract surgery. This can leave a “iridotomy-type” defect in the iris. Light sensitivity also usually resolves in more than 99% of patients. Rarely does this need to be addressed with a corneal tattoo or aniridia IOL (very rare).
NO. 5: FOREIGN BODY SENSATION
Feeling “something in the eye,” is a common complaint after ocular surgery. most often it is dryness of the ocular surface. When we used to use corneal sutures after cataract surgery, it was often the suture, but now the majority of surgeries are done without sutures.
Thus the top reasons why patients feel a foreign body after eye surgery is:
1. They feel the clear corneal incision, sideport, or limbal relaxing incision.
2. An epithelial defect after the surgery
3. Dryness due often to meibomian gland dysfunction or lacrimal gland issues in patients with Sjogrens/autoimmune disease/thyroid issues.
4. Filaments due to dryness
These are mainly treated with the following options depending on how serious the symptom:
1. Non-Preserved Artificial Tears up to every hour as needed: Retaine is usually very well tolerated but carboxymethylcellulose or hyaluronic acid lubricants an help as well.
2. A contact lens can be placed for a couple of days if severe.
3. Remove any sutures after 1 month usually (using betadine before & after suture is removed).
4. Remove filaments. Give mucomyst drops if needed
NO. 6 PAIN
This is very rare after the first 1-3 days after cataract surgery. Any continued pain needs to be addressed right away given the risk of infection/endophthalmitis. There should be no worsening of pain or vision after the first day of eye surgery.