The best way to manage patients' complaints after they undergo implantation of the Acrysof Restor lens (Alcon Laboratories, Inc., Fort Worth, TX) involves three important areas: patient selection, IOL power calculation, and preoperative counseling.
Subjectively exclude hypercritical patients, those who have unrealistic expectations, and those who do not mind wearing glasses. When first working with the Restor lens, you should also reject patients whose jobs entail driving at night, because they may have difficulty with oncoming headlights and possible halos during the first postoperative weeks. Medically, exclude patients with more than 1.00D of astigmatism and those with any preexisting pathology that will alter their contrast sensitivity (eg, maculopathy or corneal dystrophy). If they have already undergone refractive surgery, calculating the correct IOL power will be very difficult, so such patients also are not candidates for this lens. Finally, individuals who have a monofocal lens in one eye or who do not qualify for bilateral implantation are also poor candidates.
Biometry is important to achieving good visual outcomes, and all instruments should be properly calibrated. Using standard immersion A-scan ultrasound such as the Ocuscan (Alcon Laboratories, Inc.) or optical biometry such as the IOLMaster (Carl Zeiss Meditec Inc., Dublin, CA) will help avoid axial misalignment, corneal compression, or a tear bridge, which makes the eye seem slightly longer. Avoid taking measurements immediately after corneal contact. Have patients discontinue wearing their contact lenses until you can obtain stable (repeatable) corneal values. It is important for a second technician or physician to confirm readings that differ by more than 0.20mm between the two eyes. When possible, compare the patient's precataract refractive error with the bilateral IOL calculations for consistency. Use the average of multiple, consistent measurements in your calculations and delete the outliers.
The preoperative talk is probably the most important part of the process. Chair time before surgery will minimize postoperative complaints. At this point, patients are receptive and willing to listen. They will be cooperative and understanding. Addressing complications after they have occurred is problematic, because patients will be defensive and hard to comfort.
Preoperatively, patients should be aware of the possibility of nighttime issues with lights. Warn them about their potential for glare and halos but let them know that these symptoms should decrease in time. In my experience, approximately 15% of the postoperative population has certain, tolerable difficulties with nighttime driving that will slowly disappear as the weeks pass.
Explain to patients that they will attain their best visual outcome after undergoing surgery in both eyes. They should understand that the quality of their vision between procedures is not going to be completely satisfactory. If the patient expresses doubts about proceeding with the second procedure because he is not 100% satisfied with his first eye's outcome, do not hesitate to reassure him and proceed with the second operation. Write notes on your preoperative conversation in the patient's clinical chart.
During the first few postoperative days, previously hyperopic patients commonly remark that their optimal reading and intermediate (computer) distance have become shorter. As time passes, these distances will grow, but it is best to forewarn patients about this phenomenon so that they do not become worried.
Absolutely do not tell patients that they will never need glasses after surgery. Instead, inform them that they will not depend on glasses but that they may desire a minor correction in certain situations (eg, during the extended use of a computer).
Dry eyes may be a problem postoperatively. Patients who had mildly dry eyes before surgery may not have been aware of the problem, because their glasses helped to shield their eyes from exacerbating environmental factors. After surgery, patients (particularly women, in whom the condition is more common) will no longer depend on their glasses and may notice some ocular discomfort. In such cases, prescribe an ocular lubricant and, if necessary, consider punctal occlusion.
By carefully selecting patients, accurately calculating their IOL power, and counseling them appropriately, you can make implanting the Acrysof Restor lens a rewarding process. The more chair time you spend with patients before the surgery, the less will be required of you postoperatively.
Robert Kaufer, MD, is in private practice and is Medical Director of the Kaufer Clínica de Ojos in Buenos Aires, Argentina. He states that he holds no financial interest in the products or companies mentioned herein. Dr. Kaufer may be reached at +54 1 1 4733 0560; firstname.lastname@example.org.