Until recently, cataract surgery involved the replacement of the crystalline lens with a monofocal
intraocular lens (IOL). With the advent of presbyopia-correcting IOLs, however, patients can select from several types of premium lenses—most of which offer some degree of spectacles-independence but come with significant out-of-pocket costs.
Management of postoperative vision complaints is made more challenging by the sophistication of current lens designs, which has increased the potential for certain visual side effects. In my experience, complaints about suboptimal postoperative vision are best addressed by taking a logical, “decision-tree” type of approach to identifying the source of the patient’s problem and then partnering with the patient to find a satisfactory solution.
The first step is a comprehensive patient history and exam. One of the chief goals of the patient history and exam is to determine whether the patient’s complaint is a lack of visual clarity or a visual side effect (such as halos or glare). For both types of complaints, I try to evaluate possible causes in a step-by-step manner that begins with the most likely and/or most easily treatable problems.
Where the issue is visual clarity, the first step is to determine whether or not the patient has good distance vision. If my exam finds good distance acuity, the situation is usually fairly easy to resolve with spectacles or the selection of a different IOL for the second eye in the case of planned bilateral procedures.
If visual clarity is poor at both distance and near, then the situation is more complex, since the problem can originate in one of several parts of the eye: the ocular surface, the cornea, the macula, the optic nerve, and/or the posterior capsule. However, if the culprit is ocular surface abnormality or corneal irregularity, the condition is fairly amenable to treatment.
Where a number of things can cause problems with visual clarity, visual side effects tend to be related to the IOL itself, and the IOL design therefore affects the incidence and type of side effects that patients experience. In general, the greater optical complexity of multifocal IOLs makes them more likely to provoke visual side effects than accommodating IOLs, but even patients with accommodating lenses can experience visual side effects such as edge glare.
While these visual aberrations can be challenging to correct, they sometimes result simply from residual refractive error. When glare and halos occur in the absence of residual refractive error, the culprit may be the size of the pupil or its position in relation to the IOL. Finally, if none of these solutions is effective, the patient may need a YAG capsulotomy or an IOL exchange.
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