Sponsored by Carl Zeiss
This report describes the special case of a patient who initially underwent implantation of the AT LISA tri 839MP IOL (Carl Zeiss Meditec AG, Jena, Germany) in one eye. After experiencing early postoperative dysphotopsia effects, the patient demanded a lens exchange. However, after being convinced by his surgeon to allow 6 months for the visual symptoms to diminish before making a decision, the patient became very satisfied with the visual performance of the IOL at the 3-month postoperative mark and requested a second implantation in his other eye. Today, the patient continues to be happy with his overall visual outcomes after a few years. This case study shows that the
AT LISA tri 839MP IOL is designed to meet even the highest patient expectations.
A male patient in his early forties presented to AAZ with cortical cataract in both eyes. The patient, a professor of humanities, is a keen reader and had been aware of his cataract development for a long time. Given his preference for spectacle-free vision, he was interested in multifocal intraocular lens (MIOL) implantation.
The patient’s cortical cataract was more progressive in the left eye and resulted in a decimal visual acuity of OD 0.7 and OS 0.4. Both eyes were moderately myopic with -4.5 dpt in the right eye and -5.0 dpt in the left eye. The patient wore glasses and never wore contact lenses.
I recommended a postoperative refraction of -1.5 to -2.0 dpt for the left eye to increase his reading capabilities. However, the patient insisted on having an MIOL implantation in an effort to eliminate the need for glasses, even though my colleagues and I explained the risk of visual symptoms after implantation of a diffractive IOL.
We implanted the AT LISA tri 839MP IOL (Carl Zeiss Meditec AG, Jena, Germany) via a 1.8 mm temporal main incision.
The AT LISA tri 839MP (Fig.1) is a preloaded diffractive trifocal IOL with a 6.0 mm optic, an overall diameter of 11.0 mm and a posterior surface with an aberration correction of -0.18µm. The four-haptic design has square edges and a 360° rim structure to delay posterior capsule opacification. The lens is made of foldable hydrophilic acrylate with hydrophobic surface properties. It is a trifocal lens with a near addition of +3.33 D and an intermediate addition of +1.66 D, both calculated at the IOL plane.
The surgery was uneventful. The follow-up examination on the first day after surgery revealed normal pseudophakia with no signs of irritation and a normal intraocular pressure. The patient’s uncorrected decimal distance and near visual acuities were both 1.0 decimal. However, the patient complained of photic phenomena like halos, glare, and double images and demanded an immediate explantation and the implantation of a monofocal IOL. I convinced the patient to wait for at least 6 months to see whether the visual symptoms would diminish. If he was still experiencing photic phenomena after that, I offered to exchange the lens.
Although further postoperative care was morphologically uneventful, the patient presented to several well-known ophthalmic surgeons and asked for a lens exchange. Due to the good visual outcome, none of the surgeons was willing to exchange the IOL.
Three months later, the patient returned to AAZ and – instead of complaining again – asked us to implant the same lens into his right eye because he was very happy with the visual performance of his left eye.
Finally, the patient underwent cataract surgery of his right eye with implantation of the same lens model. The patient has been extremely satisfied with his visual outcome for a few years.
Discussion & Conclusion
In the beginning, this case seemed to provide further proof of unmet patient expectations after MIOL implantation, contributing to the rather low percentage of MIOL implantations compared to the total number of cataract surgeries.
The case shows that both the patient and the surgeon might be wrong in their early prognosis of the visual outcome after MIOL implantation. It is important to avoid premature decisions if visual symptoms occur during the early postoperative follow-up period. Besides neuronal adaptation, other factors may contribute to the diminishing perception of photic phenomena. Even with hypercritical patients, the increased quality of life due to a spectacle-free vision might outweigh a slight impairment due to visual symptoms and the necessary adjustment period.
This case of successful MIOL implantation in a patient with a complex and detail-focused personality demonstrates the importance of leadership and communication skills of the surgeon as well as patience from both the patient and the surgeon.
1Law EM, Aggarwal RH; Kasaby S. , European Journal of Ophthalmology, 2013; 24; 501-508
Wolfram Wehner, MD
Dr. Wehner is an anterior segment specialist. He is the managing director of the Augenärztliches Augenchirurgisches Zentrum Nürnberg (AAZ) eye clinic and its three subsidiaries. He is also a member of the board of directors of the Maximilian Eye Clinic in Nürnberg.