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Inside Eyetube.net | Oct 2013

The Fundamentals of Happiness in Cataract Patients

An organized system ensures that each patient's lifestyle and expectations are considered.

Modern cataract surgery is considered a refractive procedure, and, therefore, the visual expectations of cataract patients are very high postoperatively. A number of patients who undergo cataract surgery are convinced that the outcomes will be a sort of miracle, rendering the use of glasses absolutely unnecessary. However, as cataract surgeons are aware, not every patient will achieve emmetropia, and not every patient who does is guaranteed to be happy.

One of the fundamental aspects of managing patient happiness is gaining a full understanding of each patient’s expectations. In our department at S. Bassiano Hospital in Italy, we evaluate all patients thoroughly before surgery during the preoperative hospital visit to enable customized IOL implantation. Although this process can be demanding, it promotes patient satisfaction after surgery and minimizes the risk of a postoperative refractive surprise.


In our department, only surgeons conduct the patient’s preoperative cataract surgery visit. The surgeon collects and summarizes all of the patient’s measurements and assesses his or her visual needs and expectations. During this process, the surgeon also takes into account the examinations performed by orthoptists. Next, the surgeon explains to the patient the predicted postoperative results by evaluating all anatomic and aberrometric features of the eye.

All patients are made aware that they will need to use glasses for near vision if a monofocal IOL is implanted. For a highly myopic patient, the surgeon will take more time to consider the patient’s occupation and to understand his or her expectations from cataract surgery.

Sometimes myopic patients desire a residual myopic defect of about -2.50 or -3.00 D so as to avoid the use of glasses for near vision.

Patients with high expectations or demands undergo consultation with the chief or departmental head. The files of patients who have undergone previous refractive, corneal, or vitreoretinal surgery are highlighted and put in a special box in order to be analyzed by a specialist from that specific branch of eye surgery. Extra time is also dedicated to explaining the final postoperative refractive results to these patients.

As in every family, there is a black sheep: Some patients are just unhappy. Despite this, it is important for us to try to understand the source of their unhappiness. If necessary, we exchange the patient’s IOL or adjust his or her refraction via refractive corneal surgery. Prevention is our goal, and, in our experience, the organized system we have in place has yielded excellent results and few accidents.


Careful patient selection is crucial for premium IOL implantation. The chief problems encountered with presbyopia-correcting IOLs include blurred vision and photic phenomena (ie, visual disturbances due to optical aberrations). Causes of blurred vision can include posterior capsular opacification (PCO) and residual nearsightedness, farsightedness, or astigmatism. Causes of photic phenomena include PCO and IOL decentration.

Before recommending a lens, the surgeon must consider the sex, age, profession, and daily activities of each patient. It is best to first determine who is not eligible for premium IOL implantation. Patients who are poor candidates include those who drive at night for a living or whose occupation or hobbies depend on good night vision, patients who are amateur or commercial airline pilots, and patients who have lifelong complaints about glare. Patients with significant cataract and mild hyperopia are easiest to satisfy, but we must first make sure the patient has realistic expectations about his or her vision, including the possible need for spectacles postoperatively.

It is also important that the patient have normal eyes with a potential for vision of no worse than 0.7 (20/30) in order to achieve our goal. Routine optical coherence tomography evaluation is essential to detect any macular pathology potentially compromising the visual outcome. We prefer to use premium IOLs in eyes with corneal astigmatism of less than 1.50 D and with photopic pupil size of less than 2.5 mm. In patients with astigmatism of more than 1.50 D, we consider toric IOLs. In all cases, we stress the importance of accurate lens power calculation with adequate biometry, which aids in achieving the correct and desired postoperative refraction.

In relatively young patients with posterior subcapsular cataract, we prefer to implant accommodating IOLs. The mechanism of action of these lenses is not entirely clear, but, in our experience, accommodating IOLs work better in younger patients who are around 50 years of age. We choose to implant accommodating IOLs when the patient has an increased risk of glare or halos or when he or she needs the postoperative distance vision quality of a monofocal IOL.

It is not our habit to implant patients with a diffractive IOL in one eye and a refractive IOL in the contralateral eye, but we try to customize the implants in both eyes. In our opinion, the most important step to achieve the postoperative goal is to speak with the patient extensively before surgery, in order to understand his or her expectations and daily needs.


We have collected several surgical pearls for optimal outcomes, and thus patient satisfaction, with premium IOL implantation.

Pearl No. 1. When possible, it is better to create the main incision on the steepest corneal meridian.

Pearl No. 2. The size and shape of the capsulotomy should overlap the edges of the IOL optic around 360° in order to ensure good centration.

Pearl No. 3. It is imperative to complete cortical clean-up and posterior capsular cleaning without causing any posterior capsular break so that we can perform proper in-the-bag IOL implantation and have the lowest possible risk of PCO.

Pearl No. 4. We prefer to perform a clear corneal incision, not more than 2.2 mm, and to seal sideports only by using wound hydration. The IOL cartridge must be adequate to fit through that size incision.

The availability of various premium IOLs for presbyopia correction can complicate choosing the right IOL for each patient. Typically, we prefer to implant a diffractive multifocal or a single-optic accommodating IOL rather than a refractive multifocal IOL. Diffractive lens designs seem to have an advantage compared with accommodating designs in providing better near vision; however, disadvantages include decreased intermediate or computer-distance vision. Furthermore, patients with diffractive IOLs have a 5% chance of experiencing severe nighttime glare and halos.


Overall, do not magnify the final outcomes of cataract surgery with your patients; be realistic. Listen carefully to each patient in order to ascertain whether or not his or her expectations can be carried out. Finally, take the time to explain what modern cataract surgery can offer and what it cannot. It may seem paradoxical, but our experience has shown us that even the most demanding patients subconsciously want their excessive demands to be scaled down by an attentive physician.

Simonetta Morselli, MD, is Head of the Ophthalmology Department, S. Bassiano Hospital, Bassano del Grappa, Italy. Dr. Morselli is a member of the CRST Europe Editorial Board and states that she has no financial interest in the products or companies mentioned. She may be reached at e-mail: simonetta.morselli@gmail.com.

Antonio Toso, MD, is Head of the Vitreoretinal Surgery Unit, Ophthalmology Department, S. Bassiano Hospital, Bassano del Grappa, Italy. Dr. Toso states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: antonio.toso@gmail.com.