Negative dysphotopsia remains an enigmatic problem. In particular, there are gaps between what the optical laboratory suggests and what we witness clinically. However, certain patterns have emerged in managing patients with negative dysphotopsia. We know that negative dysphotopsia is not infrequent early after surgery and that most cases improve over time; however, those that persist beyond 6 months after surgery are unlikely to ameliorate and might require secondary surgery. Reverse optic capture, secondary piggyback IOL, Nd:YAG laser nasal anterior capsulectomy, and IOL exchange are the most common strategies that have been attempted, all with their own degrees of success.1 In general, nonsurgical strategies are unsuccessful, although blocking the inciting light from the temporal side with thick eyeglass temple pieces might be beneficial.
Although all the respondents agreed that surgery was the most likely beneficial course of action, they varied in their approaches and 2 suggested inducing miosis (with dilute pilocarpine or brimonidine) as initial therapy. On the other hand, improvement in symptoms with pupil dilation is virtually pathognomonic for negative dysphotopsia, but impractical for treatment as mentioned by Henderson. Some also wished to pursue laser nasal capsulectomy before lens-based surgery, although this strategy all but eliminates subsequent reverse optic capture.
With regard to surgery, the respondents were split over the better option between IOL exchange and a piggyback secondary IOL; however, most were in agreement that a sulcus-placed IOL in some form would best manage the negative dysphotopsia problem and that an IOL with a blue light–filtering yellow chromophore was suggested to manage the cyanopsia. Davison offered nasal truncation of an appropriate IOL, which was reported as successful by Alipati et al.2 Two European surgeons, Neuhann and Vámosi, considered an IOL exchange for the anterior capsulotomy fixated Morcher 90S IOLA as the best option; however, that device is not available in the United States and does not have a blue light–filtering chromophore. Waltz considered creating a laser posterior capsulectomy and using the posterior capsule for optic capture of the existing IOL.
In keeping with the concept that negative dysphotopsia will be alleviated if the optic edge is placed anterior to the (nasal) anterior capsulotomy, the patient requested IOL exchange. At surgery, the Tecnis toric IOL was removed from the capsular bag without incident and an iSert 231 IOL (Hoya Surgical Optics, Inc.) was implanted into the ciliary sulcus and the loops suture fixated to the iris to maintain stability and centration. That particular IOL was selected because it contains a yellow chromophore, has solid rather than extruded poly(methyl methacrylate) loops, and has a more lubricious surface character than does the Acrysof IOL. Those characteristics make the Hoya product more compatible in contact with the posterior iris. However, given that the loop diameter is 12.5 mm, suture fixation to the iris appears mandatory.
The patient noted immediate and constant relief from both negative dysphotopsia and cyanopsia. He was returned to the original surgeon to address the recurrent astigmatism.
1. Masket S, Fram NR, Cho A, Park I, Pham D. Surgical management of negative dysphotopsia. J Cataract Refract Surg
2. Alapati NM, Harocopos GJ, Sheybani A. (2016). In-the-bag nasal intraocular lens optic truncation for treatment of negative dysphotopsia. J Cataract Refract Surg, 42
, 1702-1706, Available at: http://www.jcrsjournal.org/article/S0886-3350(16)30454-0/pdf
Dr. Masket has a royalty relationship with Morcher GmbH and holds United States patents for an anti-dysphotopic IOL design.
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