Consultation section: Cataract
Because of the complexity of dysphotopsia pathogenesis, in 0.2% to 1.0% of cases symptoms might persist or only partially resolve. Negative dysphotopsia occurs with IOLs of different materials with both rounded and squared edges. The current treatment options for severe persistent negative dysphotopsia are IOL exchange with placement of a secondary IOL in the bag or in the ciliary sulcus, implantation of a supplementary IOL, reverse optic capture, and Nd:YAG anterior capsulectomy; however, in some cases the symptoms might persist after treatment. Supplementary implantation of a round-edged 6.5 mm Sulcoflex 653 L IOL (Rayner Intraocular Lenses Ltd.) can successfully treat negative dysphotopsias in approximately 70% of cases.1
In the case presented here, reverse optic capture was not successful because of the size and shape of the capsulorhexis, which was off the optic temporally and inferiorly. In general, I am not supportive of reverse optic capture of 1-piece IOLs because of the risk for iris chafing and subsequent IOP rise. I also have doubts about the stability of the toric IOL when prolapsing the optic out of the bag.
Because of the concomitant cyanopic dyschromatopsia, implantation of a clear supplementary IOL would not resolve the chromatopsia problem. Therefore, my preferred approach would be IOL exchange and reverse optic capture with a 3-piece yellow-colored (blue-filtering) IOL (eg, MN60AC, Alcon Laboratories, Inc.). I recently exchanged a Tecnis toric IOL, and this is feasible when applying careful counterforce to the zonular apparatus when releasing the haptic endings from the capsular bag adhesions. If explantation is technically not feasible, I would amputate the optic from the haptics and leave the haptics in place. Subsequently, I would place the 3-piece yellow-colored blue-filtering IOL in the sulcus. I would treat the 2.0 D of ATR corneal astigmatism with femtosecond laser arcuate keratotomies and explain to the patient that there might be some residual astigmatism postoperatively.
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1. Makhotkina NY, Berendschot TTJM, Beckers HJM, Nuijts RMMA. Treatment of negative dysphotopsia with supplementary implantation of a sulcus-fixated intraocular lens. Graefes Arch Clin Exp Ophthalmol