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Cover Stories | Feb 2009

How to Improve Results, Reduce Stress, and Have Happier Refractive IOL Patients

Three steps to success.

Refractive IOLs significantly improve the quality of life of most of the individuals who receive them, making for some of the happiest patients in an ophthalmic practice. Having just a few unhappy patients can be very disconcerting to ophthalmologists, however, can increase their stress, and reduce the quality of the doctor/patient relationship. Some physicians are choosing not to become involved with refractive IOLs, because they do not want to deal with unhappy patients. For ophthalmologists willing to move forward, this article outlines three major steps to increase postoperative success with refractive IOLs and improve surgical outcomes.

The first step when speaking with patients who are considering refractive IOLs is to set realistic expectations and address their concerns. I openly discuss the possibility of glare, halos, and reduced quality of vision. I inform patients that achieving crisp reading vision may cause secondary visual phenomena. I explain that most patients do not experience these phenomena but that they are well accepted by the majority in whom they occur. I stipulate, however, that the occasional patient will experience significant glare and halos. Additionally, I emphasize that glare and halos are normal phenomena that occur early on following surgery and tend to resolve over time.

Because many individuals with glare and halos after refractive IOL surgery may have a residual refractive error, I explain to prospective patients that they may need enhancement surgery, such as limbal relaxing incisions or excimer laser photoablation. I tell them about what I term the 5 Cs for unhappiness after refractive IOLs: cylinder and residual refractive error, corneal and ocular surface disease, capsular opacities, cystoid macular edema (CME), and centering of the pupil on the IOL. I advise patients that these potential postoperative problems are a normal part of the experience, and I assure them that we will partner together in managing any problem they may have after surgery.

When I speak with patients prior to surgery, I emphasize the importance of their participation in improving their refractive outcomes. Certainly, the most dreaded complication of cataract surgery is endophthalmitis. I therefore educate patients about the importance of using their antibiotic drops religiously pre- and postoperatively. Because Moshirfar et al found that the mean time to endophthalmitis was 9.3 days,1 I now recommend that patients continue prophylactic treatment for at least 10 days following surgery. I believe the use of a fourth-generation fluoroquinolone, such as gatifloxacin or moxifloxacin, reduces the risk of this complication.

Although endophthalmitis is a serious concern, a more common cause of reduced quality of vision following cataract surgery is CME. This condition has been redefined to include any patient who has even moderate macular thickening, which has been shown to degrade vision. Owing to the inherent loss of contrast sensitivity with multifocal optics, patients who receive these lenses can less afford to have their quality of vision reduced by CME than those who receive monofocal IOLs. It is imperative to reduce the risk of this complication in the recipients of multifocal lenses. I routinely perform preoperative optical coherence tomography (OCT) on patients who are choosing to receive refractive IOLs, because the presence of epiretinal membranes or lamellar macular holes increases the risk of CME.

A large multicenter study by Wittpenn et al showed that the use of an NSAID (ketorolac tromethamine) reduced the incidence of clinical CME essentially to zero.2 Because the incidence of CME peaks at 4 weeks postoperatively, I routinely instruct patients receiving refractive IOLs to start using an NSAID 3 days preoperatively and to continue its administration for 1 month postoperatively in order to improve macular quality and reduce inflammation. For patients who are at increased risk of CME (eg, those with a history of CME after previous cataract surgery, diabetes, epiretinal membrane, etc.), I now prescribe the new corticosteroid difluprednate 0.05% (Durezol; Sirion Therapeutics, Tampa, FL). This agent has been shown to treat inflammation more effectively than prednisolone acetate,3 and it may further reduce the risk of CME and increase corneal clarity immediately following surgery.

The most common cause of reduced quality of vision following cataract surgery is ocular surface disease, which is common among patients over the age of 55. The corneal incision, the use of medications, and limbal relaxing incisions (when needed) further degrade the tear film, reduce corneal sensitivity, and increase the scattering of light. I perform a dry eye workup on any patient who has chosen a refractive IOL, just as I would for LASIK candidates. If I see corneal staining or significant conjunctival staining, I will not consider a refractive IOL until these problems have been resolved. For all patients undergoing refractive IOL surgery, I now routinely prescribe cyclosporine 0.05% for a minimum of 2 weeks preoperatively and at least 3 months postoperatively. The tear film is the definitive refracting surface of the eye; improving it augments visual outcomes.4

Although the great majority of patients are extremely happy after refractive IOL surgery, it is that one unhappy patient whom ophthalmologists remember. The key in my practice is to prevent a patient from ever becoming unhappy with me.

In the past, when the occasional unhappy patient would tell me that he was experiencing glare, halo, or reduced quality of vision following cataract surgery and would ask me what I was going to do about it, I had no information other than his visual acuity and could not begin to speak intelligently about the problem. Before I could offer any suggestions, I would generally perform my examination and order some tests. By this point, the concerned patient was even more unhappy to have no real information and would often complain aggressively. The doctor/patient relationship had changed irrevocably.

Today, when a patient is, or seems to be, unhappy after receiving a refractive IOL, my staff routinely performs topography, a refraction, and OCT. They alert me to the situation before I speak with the patient and provide me with the data from the aforementioned tests to review. I certainly want to know about any residual refractive error before talking to the patient, but I also want to look at the topography for residual cylinder. The topographic map will also often show a dropout of information, which will serve as a warning that the patient has significant dry eye. I also review the OCT scan for CME.

When I walk into the examining room and meet the patient, I am armed with information. I do not even give the patient a chance to speak to me first. I simply greet him and say that he must be unhappy with his surgical result so far. I describe his problem (eg, refractive error, dry eye, CME, residual cylinder) and state that any patient with these findings would not have the best visual acuity. I tell him that I know what the problem is and reassure him that we will work together to resolve it. By speaking to the patient in this manner, I have agreed with him that he is unhappy, I have not given him a reason to be angry, and I have developed a treatment plan that will resolve his problems. The patient and I are now on the same team.

The single most incendiary statement to make to a dissatisfied patient after refractive IOL surgery is, "You should be happy with your result." This remarks creates a confrontation and almost always makes the patient angry. If there is one pearl that I have for all ophthalmologists, it is that, no matter what a patient says, it is never okay to tell him, "You should be happy." Patients have the right to be unhappy, and it is the ophthalmologist's job to attempt to solve their problem. Sometimes, a solution will not be possible, but the surgeon must exhaust all possible remedies first. When resolution is impossible, the surgeon must honestly explain and demonstrate that he has tried everything before saying there is no solution.

Following the guidelines of an appropriate informed consent, using the correct pharmaceutical agents to increase the odds of a successful result, and dealing proactively with the occasional disappointed patient will dramatically reduce, if not eliminate, the number of unhappy refractive IOL patients in one's practice. I look forward to seeing my patients following cataract surgery and, particularly, after refractive IOL surgery. The latter are extraordinarily happy. The rare unhappy individual can be treated effectively without compromising the physician/patient relationship. With attention to residual refractive error, the ocular surface, CME, the posterior capsule, and the pupil's centration over the IOL, I believe surgeons can satisfy most patients who are unhappy with their refractive IOLs. More important is dealing with patients as individuals and making certain that they know that their ophthalmologist is on their side and working to resolve their problems.

Eric D. Donnenfeld, MD, is a trustee of Dartmouth Medical School in Hanover, New Hampshire, and is Partner in Ophthalmic Consultants of Long Island in Rockville Centre, New York. Dr. Donnenfeld may be reached at (516) 766-2519; eddoph@aol.com.

  1. Moshirfar M, Feiz V, Vitale AT, et al. Endophthalmitis after uncomplicated cataract surgery with the use of fourth-generation fluoroquinolones: a retrospective observational case series. Ophthalmology. 2007;114(4):686-691.
  2. Wittpenn JR, Silverstein S, Heier J, et al. A randomized, masked comparison of topical ketorolac 0.4% plus steroid vs steroid alone in low-risk cataract surgery patients. Am J Ophthalmol. 2008;146(4):554-560.
  3. Korenfeld MS, Silverstein SM, Cooke DL, et al. Difluprednate ophthalmic emulsion 0.05% for postoperative inflammation and pain. J Cataract Refract Surg. 2009;35(1):26-34.
  4. Perry HD, Donnenfeld ED, Roberts C, et al. Efficacy of topical cyclosporine vs. tears for improving visual outcomes following multifocal IOL implantation. Poster presented at: The AAO Annual Meeting; November 10-11, 2007; New Orleans, LA.
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