With modern multifocal lenses and advanced intraocular lens (IOL) power formulas, it’s becoming more rare that one would need to explant a presbyopic IOL. Moreover, most surgeons have become adept at appropriately setting patient expectations, far better than 10 or 15 years ago during the early stages of multifocal IOLs and enhanced depth of focus (EDOF) lenses. In my practice, my explant rate with presbyopic IOLs is far less than 1%.

Still, even with the latest equipment, advanced lenses, and flawless surgical technique, at times you’ll need to explant a presbyobic IOL. In this article, I offer you tips and techniques to ensure these patients leave your office feeling pleased and satisfied with the outcome.

Concerns About Contrast

Rarely do I find that patients want to change a lens because of glare, halo, or starburst. More often than not, a cataract-age patient doesn’t drive a great deal at night, so seeing glare, halo, or starburst is not a huge issue for them.

Typically, the reason for the change involves poor contrast. The patient may be 20/10 and J1 and not have much residual prescription but feels that his/her vision isn’t crisp. For instance, the patient may see shadowing around the letters of a license plate. This is the type of patient who is usually headed toward a lens exchange.

Less often, the patient’s personality is such that they can’t accept any compromise in the quality of their vision to have much better quantity of vision. They shouldn’t have had a multifocal lens in the first place. They may present as a good multifocal candidate to you but may act differently with your staff. Listening carefully to your staff about a patient’s attitude and personality can help to avoid this predicament.

Some feel that type A personalities may not be good candidates for multifocal IOLs, but these can be some of your happiest patients. If you set the appropriate expectation with them and answer all of their questions, they can be highly satisfied.

Pearls for Lens Removal

As a first step, when it comes to removing the lens, ensure proper sedation. You may want to consider doing the procedure in an ambulatory surgical center with intravenous sedation.

To ensure that the procedure is as atraumatic as possible, use microsurgical scissors so you don’t have to make a large wound. In my practice, I use MicroSurgical Technology (MST) Micro-Graspers and MST Micro-Scissors.

When I enter the eye, I use the same wound as the initial lens. Typically, this is at the angle I want to use. What’s more, usually I’m replacing the lens 2 or 3 months after the initial lens was placed. The wound will open easily, with no need to use a keratome.

Using the same wound, I also can delay possible astigmatic effects of multiple incisions in the cornea. I don’t want to add any vectors of astigmatism if I can avoid it.

Entering the eye, I use a large amount of dispersive viscoelastic, placing it underneath the anterior capsule and into the intracapsular bag, preferably along the haptic-optic junction in the elbow area of the haptic-optic interface. I then gently place viscoelastic along the line of the haptic. I follow the haptic back posteriorly into the equator of the intracapsular bag to free any adhesions that the intracapsular bag may have with the haptic.

I do this on both haptics. If needed, I make another paracentesis to gain enough access to provide a good angle of attack on these haptics.

Once the haptics are free, I nudge the optic, spinning it slightly to ensure that it moves freely in the capsular bag. Once it spins freely, I rotate the IOL up into the anterior chamber and have it rest on the surface of the iris.

I then place more viscoelastic above and below the IOL. At this point, I use the Micro-Forceps and Micro-Scissors to cut the IOL in half and remove both halves one after the other. Finally, I inject more viscoelastic prior to inserting the new lens.

Moving to Monofocal

After removing a multifocal lens, I typically replace it with a monofocal lens. I’ve prepared the patient for this, and they understand that they’ll have to use readers or bifocals.

Rarely, a patient will choose an EDOF lens for minimal glare and halo at night and believes J1 or J2 vision will work for up-close vision. Quickly, patients may realize they want even better near vision. In that instance, I occasionally will replace an EDOF or multifocal-light lens with a stronger multifocal for reading. In general, I do not swap a multifocal lens, such as an Odyssey, Synergy or PanOptix, for a different type of multifocal.

Typically, I’ll implant the new lens in the capsular bag. If, in removing the lens, there is zonular dialysis or dehiscence, I may implant a 3-piece IOL, such as the LI61AO from Bausch + Lomb, in the sulcus for stability.

Postoperatively, you may want to use a typical schedule of follow-up at 1 day, 1 week, and 1 month. I give the patient the 3-in-1 ImprimisRx drop (prednisolone acetate, moxifloxacin, and nepafenac), which they use twice a day for roughly 3 weeks.

No Rush

In deciding whether to replace a presbyopic lens, you’ll want to wait at least 3 months before making that decision. Give your patients time to neuroadapt to their new vision. I tell patients that it took a long time for their eyes to reach this stage, and it’s going to take a little time for their eyes to get better. They usually understand this.

However, make sure to identify any patient who is vehemently unhappy with the new IOL. Listen for buzzwords and phrases, such as when the patient says something like, “This is the worst decision I’ve ever made,” or “I can’t go on like this.” The patient clearly is trying to tell you that the new IOL isn’t working, and you need to solve the problem sooner rather than later. Don’t let that patient wait 3 months for an explant because the patient will be miserable and tell everyone in town how unhappy they are for those 3 months.

Having mixed emotions about an outcome, meaning there are some things you like and some things you don’t like, is very different than being vehemently unhappy. These 2 situations are different, and your threshold for explantation should be different.

From a surgical perspective, doing the explant sooner usually makes for an easier procedure.

The longer you wait to replace a lens, the more difficult the procedure may be. For instance, if you’re explanting a lens 2 years after it was placed, you may have to use more viscoelastic and may have to suture in an IOL if you run into an issue with the capsular bag.

From a practice viewpoint, you don’t want an unhappy patient walking around for a long time and telling friends and family how bad an experience they had. In these rare cases, you need to replace the lens, and 99 times out of 100 that patient will end up very pleased, or at least as happy as they are capable of being.

Gaining Satisfaction

Today, we can be more accurate with our refractive outcomes than ever before, almost entirely eliminating the need to explant a presbyopic IOL. In those rare cases in which the lens must be replaced, these techniques can help you turn an unhappy patient into a satisfied one. 

Disclosures

Dr. Williamson is a consultant for Johnson & Johnson, Bausch + Lomb, and Harrow Health.

Dr. Williamson is a third-generation eye doctor specializing in refractive surgery, cataract, and minimally invasive glaucoma surgery. He is an owner of and partner in Williamson Eye in Baton Rouge, LA.