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Consultation section: Cataract

February consultation #9

Lubeck, David MD

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Journal of Cataract & Refractive Surgery: February 2018 - Volume 44 - Issue 2 - p 251-252
doi: 10.1016/j.jcrs.2018.02.010
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Successful treatment of the combination of aberrations and altered color vision narrows the therapeutic decision tree. As a final diagnostic maneuver, I would recommend that the patient try Symbol% to Symbol% pilocarpine 2 times daily for 2 to 4 weeks. If pharmacological miosis decreases the dysphotopsia, it might also lessen the intensity of blue colors. Should the patient feel that this has adequately improved the symptoms, pilocarpine can be continued for a minimum of 3 months to reset the pupil size.

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If miosis does not lessen the negative dysphotopsia or dyschromatopsia is persistent, and IOL exchange with concurrent femtosecond limbal relaxing incision (LRI) and intraoperative aberrometry or consecutive photorefractive keratectomy (PRK) and LASIK could be considered. Surgical release of the originally implanted IOL is feasible, even 2 years after its insertion. Viscodissection of the haptics will usually completely free them. If peripheral capsule fibrosis prevents the release of 1 or both haptics, they can be amputated with IOL scissors beyond the haptic–optic junction. The distal portion of the haptic is left in the capsule. A blue-filtering 3-piece IOL would be sulcus fixated with haptics oriented in the opposite meridian from the original. Concurrent femtosecond laser LRIs could correct preexisting corneal astigmatism, and intraoperative aberrometry would increase the accuracy of IOL power calculation. Alternatively, the power of the 3-piece blue-filtering IOL could be determined with conventional calculations and PRK/LASIK could be performed 2 to 3 months later to most accurately correct astigmatic and spherical refractive errors.

I believe that the latter approach has the greatest chance of eliminating both the negative dysphotopsia and dyschromatopsia while providing the best UDVA with spectacles. It does not require the long-term use of drops or a specialty contact lens. The risks are similar to those of cataract surgery and therefore should be acceptable. The previous use of LASIK in the fellow eye would support its use to optimize the result of the eye in question. Finally, should the patient ask what I would do if it were my eye (as they often do), I would reinforce that the treatment is his decision and answer that I would chose this course of action for myself.

© 2018 by Lippincott Williams & Wilkins, Inc.