This is a very complex problem because of the intolerable negative dysphotopsia in the face of an otherwise excellent visual and anatomic outcome. Over time, I have become impressed with the intensity of the dissatisfaction patients can have with negative dysphotopsia. For that reason, I will go to great lengths to reduce or minimize negative dysphotopsia, including the risk for being surgically creative to solve the problem.
Because this patient has a seemingly perfect anatomic outcome, it is tempting to downplay the patient’s symptoms in an effort to “first, do no harm.” Therefore, the first step in helping this patient is to accept that a perfect anatomic result might, rarely, require further surgery.
Reverse optic capture, piggyback IOLs, and IOL exchange have all been advocated as possible treatments for negative dysphotopsia. This patient has already had a very appropriate attempt at reverse optic capture that was unsuccessful because of limitations of the anterior capsulotomy configuration.
I am reluctant to offer piggyback IOLs as an option when there might be other alternatives. One of the poorly understood limitations of all IOLs is surface reflection. The typical IOL has 2 surfaces to create annoying internal reflections in the pseudophakic eye. With a piggyback IOL, there are an additional 2 surfaces that might induce internal reflections. The piggyback IOL tends to have less curved surfaces because of its lower power. The less curved surfaces tend to cause more problematic reflections.
An IOL exchange for a new type and configuration of IOL is tempting but can create other issues and might or might not solve negative dysphotopsia. There are no good toric IOL alternatives for exchanging a toric IOL in this situation. Although I prefer IOL exchange over a piggyback IOL to treat negative dysphotopsia, the toric IOL complicates the decision tree.
It would be possible to create optic capture with the posterior capsule. The anterior and posterior capsules have, almost certainly, fused. They can be treated as 1 entity. A 5.0 mm posterior capsulotomy centered on the current optic could be created with an Nd:YAG laser or femtosecond laser as step 1. The IOL could then be captured through the posterior capsulotomy as step 2. This would mask the IOL edge and likely minimize the negative dysphotopsia while preserving the existing refractive outcome. If the posterior capsulotomy and optic capture were not successful, a piggyback IOL could then be implanted without additional risks.
I strongly suspect the cyanopic dyschromatopsia will improve with resolution of the negative dysphotopsia. If not, a tinted contact lens can be used.