THERE ARE SOME VERY GOOD INTRAOCULAR LENSES (IOLS) for use in patients with presbyopia, but despite our best efforts in selecting the best lens for the patient’s needs and in setting appropriate expectations, we still occasionally have patients who are not happy after receiving an IOL.

Listen to Your Patient

The first thing I bear in mind is that the patient almost certainly is complaining about something real, something that is actually bothering them. I think sometimes we run to the idea that a patient is high maintenance or demanding. In fact, they’re just frustrated because their eyes aren’t working the way that they want them to. I think we all need to start with that premise and fight really hard to solve the problem.

The second thing is that people don’t care what you know until they know that you care. So I want to really make them feel that I care because I do. We need to care and empathize with our patients and then never give up trying to help them solve their problems.

Those are probably the two most important things.

Address Ocular Surface Before Adjusting Refraction

The most common reason patients aren’t happy after an IOL procedure is because of a little bit of refractive error — some astigmatism or residual myopia or hyperopia.

But before fixing that, you really have to make sure that the ocular surface is tuned up. Be sure that the ocular surface is clear and clean; use punctal plugs, maybe a burst of steroids, and maybe an eye lid massage procedure to improve any meibomian gland dysfunction that might exist. Ideally, the surface is cleaned before surgery, but sometimes it isn’t performed as completely as needed.

Making an Adjustment

Because the issue frustrating a patient is frequently due to a refractive error, I believe that among the most under utilized tools in treating presbyopia IOLs (in the early postoperative period) is a pair of glasses -- just a thin pair of glasses they can use until we do our LASIK enhancement.

If we refract them and they get to 20/20 from 20/25-, they can wear those glasses and will feel better because they know at least they can see well.

So if they love their vision with glasses, you know a LASIK enhancement is going to be the answer. If the patient develops posterior capsular opacification, you’ll need to perform a YAG capsulotomy, or they won’t have good vision. But you’re not left wondering whether it’s a refractive error that can be fixed or a lens and positive dysphotopsias that can’t be.

Near Point Matters

I think it’s really important to understand the near point of the different lenses. If you choose a TECNIS multifocal ZMB00 or a ReSTOR +4.0, their near point would be really close, and their distance vision would be at infinity. And they have a no man’s land, from computer distance to where patients can’t see the labels on cans at the grocery store.

So the different lenses have different near points, and you really want to try and cover distance, intermediate, and near. Trifocals do that now, so they’re a great solution, probably the best solution right now in many cases. They give you a lot of freedom of both eyes working together at all distances. But if you’re going to use bifocal IOLs, you really need to understand where the near point is to ensure that you’re getting a patient’s vision where they want it.

Don’t Be in a Hurry

The other thing to bear in mind is that time is our friend. If I pay attention, I can see the shadow of my nose or the rim of my glasses. But our brain learns to filter out that extraneous information as non-useful. It’s a big adjustment as a person going through cataract surgery gets used to their new lenses, and time is our friend in helping them with that.

Gas-permeable Lenses

If refraction doesn’t get the patient to a crisp 20/20, my next step is a gas permeable over-refraction to cover up the anterior cornea and see whether there’s some irregular astigmatism or anterior basement membrane dystrophy that’s causing a problem. If the vision becomes crisp with a gas-permeable lens over-refraction, but it wasn’t crisp with a regular refraction, then we know the cornea is the issue, and I need to work on polishing the cornea.

IOL Exchange

If all of those things fail, and the patient has positive dysphotopsias, or they talk about having non-crisp vision, then I think it’s time for an IOL exchange, probably moving to a standard monofocal lens. This does happen of course in some cases.

I tell all my patients we’re going to go down this road together. I point out these lenses aren’t as good as their natural lenses at age 20, but they’re the best we’ve come up with, and most patients love them. I do tell them not everybody is happy, and once in awhile, we have to take a lens back out. I assure them I’ll be by their side the whole way. ■

Dr. Berdahl is a board-certified ophthalmologist practicing at Vance Thompson Vision in Sioux Falls, SD. His published work has primarily focused on the fundamental causes of glaucoma, MIGS, and astigmatism management during and after cataract surgery.