Despite our efforts to consistently deliver optimal surgical results, visual complaints do arise among patients who have undergone cataract and refractive surgery. However, there are steps the surgeon can take both pre- and postoperatively to reduce the likelihood of facing an unhappy patient.
In determining which surgical approach will most benefit each patient, it is essential to conduct a thorough preoperative evaluation and to learn about the patient’s lifestyle; once a treatment has been selected, establishing reasonable patient expectations for the procedure is key. When a patient is dissatisfied with his or her postoperative results, there are several methods to help minimize discomfort and maintain a healthy doctor-patient relationship.
No. 1: Use of eyeglasses after cataract surgery
One of the most frequent questions we hear from referred patients using correction after cataract surgery is, “Doctor, is it normal to use eyeglasses after cataract surgery? A friend of mine who had the same procedure years ago never needed any correction.”
In order to avoid this situation, patients should be informed preoperatively of all the potential outcomes of a procedure. It is advisable to ensure that patients have reasonable expectations and are aware that they may need to wear eyeglasses afterward. They should also understand that a second procedure may be required in the event of significant residual refractive error in the postoperative period. Above all, it is important to have a thorough conversation to learn about patients’ personalities and lifestyles, as this will help to determine whether they are good candidates for monofocal (monovision strategy) or multifocal IOLs. We always try to under-promise and over-deliver.
The relationship between the patient and the surgeon will not be damaged if the surgeon speaks clearly about the goal of surgery—to reduce spectacle dependence— rather than promising complete spectacle independence after surgery. If the postoperative results are not what a patient had hoped for, he or she has reason to be dissatisfied; however, if the patient was made aware of the potential need for spectacles, he or she will likely still have confidence in the surgeon, despite the results. The patient and surgeon can then work together to search for the best option to solve this inconvenience.
No. 2: Dry eye after refractive surgery
It is common for surgeons to hear complaints of dry eye after uneventful refractive surgery. Usually, this occurs in the late postoperative period, after the patient’s initial enthusiasm about seeing without optical correction (contact lenses or eyeglasses). In order to prevent this uncomfortable situation, preoperative evaluation of the tear film and its stability must be performed with extra care. If the tear break-up time is normal, the surgery may be scheduled; however, if it is not acceptable, the patient should be diagnosed with dry eye and the surgery postponed until the condition is remedied. This is because the patient’s existing dry eye will be exacerbated after excimer laser surgery, whether LASIK, PRK, or LASEK. The most common causative factors for tear film instability are the presence of blepharitis and meibomitis. If these are detected, they must be treated before and after surgery, especially after LASIK, because excessive meibomian secretions are associated with greater risk for diffuse lamellar keratitis.
No. 3: Dysphotopsias including halos, glare, and dark shadows
Complaints of dysphotopsias are common after cataract surgery, regardless of the type of IOL implanted, although they are more prevalent with squared-edge IOLs. If a patient with these complaints comes to our attention, the first detail we look for is IOL centration—whether the optic is centered in relation to the pupil and the lens position is well centered in the capsular bag or sulcus. If we observe good IOL centration, we can explain to the patient that the surgery was well performed and these symptoms will become less distressing over time, before disappearing in a few months without any further need for treatment. In a few cases in which the patient is very unhappy, we will prescribe an alpha-agonist such as brimonidine tartrate (Alphagan; Allergan, Inc.) to reduce pupil size, which, in most cases, reduces the symptoms. On the other hand, if the IOL is not well centered, we explain the situation to the patient and, depending upon the severity of the symptoms, decide whether to observe or to perform a surgical adjustment.
No. 4: Photophobia
Photophobia is common after cataract and refractive surgeries, especially among patients with light-colored (blue or green) irides. It usually starts during the early weeks after the procedure. In our preoperative discussion with patients, we tell them that there is a possibility they may experience discomfort with light; however, we also explain that, in the vast majority of cases, this discomfort is transitory and will become less disturbing within weeks or months. During this period, the use of sunglasses will provide comfort, should the patient choose to wear them. If the photophobia is bothersome and cannot be managed with sunglasses, miotic drops (pilocarpine 2%) can be used temporarily during the morning to reduce pupil size.
No. 5: Foreign Body Sensation
When a patient complains of a foreign body sensation, the first item to rule out is the presence of a foreign body on his or her ocular surface that can be removed immediately.
On the first postoperative day, the most common finding is the presence of a suture that is not well buried; this situation can be managed with application of a contact lens for 1 week until the suture can be removed without compromising the surgical result. If no suture was used, the foreign body sensation is usually caused by an epithelial defect around a clear corneal, sideport, or limbal relaxing incision. It may sometimes be associated with filaments of cotton from the swabs used to check the integrity of the incision at the end of the procedure. Although this epithelial defect produces a foreign body sensation, most patients tolerate it well and do not require any further treatment besides lubricant. If it is not well tolerated, a contact lens can be placed for a couple of days.
Additionally, when the surgeon sees filaments of cottons in the incision, it is important to double-check whether they are in the inner wall of the incision; in cases in which these filaments make connections with the ocular surface, they must be removed with delicate forceps to avoid endophthalmitis.
In the late postoperative period, there are two basic situations for complaint of foreign body sensation: (1) a loose suture, which must be removed immediately to avoid secondary infection (late endophthalmitis), and (2) ocular surface deficiency, which can be treated with carboxymethylcellulose or hyaluronic acid lubricant drops while we search for associated disease such as blepharitis and/or meibomitis.
Daniela M.V. Marques, MD, PhD, is a Medical Director at the Marques Eye Institute in São Paulo, Brazil, and a Medical Collaborator in the Research Department of the Cataract Sector of the Federal University of São Paulo. Dr. Marques states that she has no financial interest in the material discussed in this article. She may be reached at tel: +55 11 99252 1925; e-mail: dradaniela@marqueseye. com.br.
Frederico F. Marques, MD, PhD, is a Medical Director of the Marques Eye Institute in São Paulo, Brazil, and a Medical Collaborator in the Research Department of the Cataract Sector of the Federal University of São Paulo. Dr. Marques states that he has no financial interest in the material discussed in this article. He may be reached at tel: +55 11 98292 3082; e-mail: email@example.com.