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Consultation section: Cataract

February consultation #8

Olson, Randall J. MD

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Journal of Cataract & Refractive Surgery: February 2018 - Volume 44 - Issue 2 - p 251
doi: 10.1016/j.jcrs.2018.02.009
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Pseudophakic dysphotopsia is the most important dissatisfier for patients after successful cataract surgery.1,2 Bothersome cyanopic dyschromotopsia is rare, especially if both eyes have a similar wavelight transmittance. A few principles that have helped me address such challenging patients are as follows:

  1. We see with our brain, and it makes sense that pseudophakic dysphotopsia is going to be reported by those who are more likely to be inflexible in general.
  2. These patients have often been given the sense that they are “problem patients” best to be ignored, which only aggravates the problem, so take the time to listen and take them seriously.
  3. Lingo gets thrown around and patients are rapidly pigeonholed. Always ask patients to describe their symptoms in their own words.

In the current case, the cyanopic dyschromotopsia is a result of the clear IOL. In addition, if negative dysphotopsia is truly present, it is an IOL edge effect, as best defined by Holladay et al.,3 or the overlapping capsule, as described by Masket and Fram.4 I believe both hypotheses are relevant.

Sometimes a discussion alone can be enough. Brimonidine rarely helps negative dysphotopsia; however, it is worth a try, even as a placebo and to buy time. Next, I would amputate the offending overlapping capsule. If the negative dysphotopsia persists, with a well-fixated and aligned toric IOL in place already, implantation of a sulcus-fixated piggyback IOL with a 3-piece silicone IOL would be my next step. If pigment dispersion syndrome (PDS) is seen, the piggyback IOL has to come out because the resultant glaucoma can be very hard to treat.

A definitive treatment would be a blue light–filtering IOL for IOL exchange or as a piggyback. Knowing that the negative dysphotopsia is resolved by amputating the anterior capsule overlap tells me that an IOL exchange with a blue light–filtering toric IOL will work. This patient must be told that freeing the capsule and obtaining good axis alignment might be tricky. Here is where I can often get a patient to agree that with the negative dysphotopsia resolved, the cyanopic dyschromotopsia might be tolerable. If the negative dysphotopsia persisted with no anterior capsule overlap, a blue light–filtering piggyback IOL should only be a consideration if there were generous posterior chamber space, given the risk for PDS.

References

1. Welch NR, Gregori N, Zabriskie N, Olson RJ. Satisfaction and dysphotopsia in the pseudophakic patient. Can J Ophthalmol. 2010;45:140-143.
2. Kinard K, Jarstad A, Olson RJ. Correlation of visual quality with satisfaction and function in a normal cohort of pseudophakic patients. J Cataract Refract Surg. 2013;39:590-597.
3. Holladay JT, Zhao H, Reisin CR. Negative dysphotopsia: the enigmatic penumbra. J Cataract Refract Surg. 2012;38:1251-1265.
4. Masket S, Fram NR. Pseudophakic negative dysphotopsia: surgical management and new theory of etiology. J Cataract Refract Surg. 2011;37:1199-1207.
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