At A Glance

  • Before we even discuss with patients how to correct their refractive error, we should address any existing ocular surface disease.
  • Posterior capsular opacification is a common complication of cataract surgery and can manifest at any time, from a few months to years after implantation of an IOL.
  • Unwanted visual disturbances (ie, positive, negative, and diffractive dysphotopsias) can occur after any uncomplicated cataract surgery.

We have all encountered unhappy patients who are dissatisfied with their outcome after cataract surgery. Often these patients are at the 5-yard line, ready to score a touchdown. A key to getting them into the end zone is taking time to explore and understand what is bothersome or frustrating to them.

In this article, we discuss the most common reasons patients report being unhappy and suggest solutions to help them cross that goal line from 20/unhappy to 20/happy.


Residual refractive error is a common reason for patient dissatisfaction after cataract surgery. Fortunately, this can be corrected with a pair of glasses or contact lenses or with a corneal refractive procedure. With refractive cataract surgery rising in popularity, it is vital to manage patients’ expectations to ensure their happiness with their results. Communicating to patients ahead of time that they may still need part-time glasses or contact lenses or a corneal refractive fine-tune procedure to get them where they want is important to achieving a 20/happy outcome.


It is crucial to manage the ocular surface before surgery, and it is just as important to manage the ocular surface after surgery. In fact, before we even discuss with patients how to approach correcting their postoperative refractive error, we treat and optimize the ocular surface, as this could be the cause of their dissatisfaction and/or refractive error. Even if a patient doesn’t present with classic complaints of ocular surface disease (OSD) (eg, fluctuations in vision, foreign body sensation), we recommend pursuing a dry eye workup for anyone who is unhappy with their quality of vision postoperatively.

If a patient does have OSD before surgery, it’s important to communicate to the patient the impact this can have on surgical outcomes due to unreliable measurements, ocular comfort, and quality of vision. The reported incidence of dry eye disease in patients undergoing cataract surgery is highly variable. One study evaluated the incidence of dry eye syndrome in patients being screened for cataract surgery and found that out of 136 patients, 63% had a tear breakup time of less than 5 seconds and 77% had corneal staining.1 A host of factors can contribute to a poor ocular surface, and undergoing surgery can transiently exacerbate the signs and symptoms.

It is important to recognize common OSD complaints such as fluctuating vision, reduced visual acuity, and eye irritation, and to initiate a comprehensive dry eye workup in patients who are unhappy with their quality of vision postoperatively.


Posterior capsular opacification (PCO) is a common complication of cataract surgery. It can manifest any time from a few months to years after implantation of an IOL. The incidence of PCO ranges from <5% to as high as 50%, and the onset of PCO can create visual frustration for patients and the feeling that their cataracts are returning.2,3 Once PCO is identified, an Nd:YAG capsulotomy can be performed to get patients back to where they want to be.


Positive, negative, and diffractive dysphotopsias are unwanted visual disturbances that can occur after any uncomplicated cataract surgery.

Positive dysphotopsias, which patients often report as halos, streaks, or arcs in the periphery of their vision, are most commonly associated with IOL edge design and IOLs with higher indices of refraction. Negative dysphotopsias, which are not as widely understood, are often reported by patients as a dark shadow in their temporal vision. Diffractive dysphotopsias are associated with the diffractive properties of IOLs and are commonly reported visually as halos.4

Regardless of the classification or cause, it is important to allow time for neural adaptation. If after 3 to 6 months the patient’s complaint is persistent, it is important to dive deeper and understand how bothersome it is for him or her. If all conservative treatment options have been executed, a lens exchange may be necessary in rare cases.


The typical patient scenario for problematic near point occurs when a patient chooses a presbyopia-correcting IOL and is not satisfied with his or her near vision after surgery. Despite presurgical explanations of reasonable expectations, some patients still expect to see J1+ postoperatively. No matter the extent of the preoperative discussion, these patients remain dissatisfied.

A tool we like to use in these situations is a trial lens set and a few loose lenses. In these scenarios, we demonstrate to patients what their near vision would be if they had selected a monofocal implant. This can be powerful. In some cases, we ask patients to look at their phones or at reading material and we place two -2.50 D loose lenses over each eye. When they see the result, often these patients realize that their implants are providing functional near vision.


As the primary eye care providers for our patients, we have the best understanding of each patient’s visual goals. Armed with this information, we are uniquely suited to educate these patients on their IOL options. After the initial discussion, we can help by communicating these findings to the surgeons we work alongside in order to avoid implantation of an IOL that would not fit these patients’ visual needs.

For visually demanding patients, expectation management is even more important than it is for more tolerant patients. Spending extra chair time preoperatively will pave the way for more 20/happy outcomes. We can never overeducate a patient with regard to proper expectations.


With elevated patient expectations and the array of options available today, modern cataract surgery is essentially a refractive surgical procedure. Technologies and options are rapidly evolving, and patients look to optometrists as their primary eye care providers. They expect us to provide good guidance and educated recommendations. If you adopt the six troubleshooting tools we have outlined here, we predict that you will have more of your patients doing the touchdown spike.

  • 1. Trattler WB, Majmudar PA, Donnenfeld EG, McDonald MB, Stonecipher KG, Goldberg DF; PHACO Study Group. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: the effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.
  • 2. Raj SM, Vasavada AR, Johar SRK, Vasavada VA, Vasavada VA. Post-operative capsular opacification: a review. Int J Biomed Sci. 2007;3(4):237-250.
  • 3. Vasavada A, Shetal MR, Shah GD, Nanavaty MA. Posterior capsule opacification after lens implantation; incidence, risk factors and management. Expert Rev Ophthalmol. 2013;8(2):141-149.
  • 4. Masket S, Fram NR. Pseudophakic Dysphotopsia: A review of incidence, etiology and treatment of positive and negative dysphotopsia [published online ahead of print, 2020 Aug 12]. Ophthalmology. 2020;S0161-6420(20)30787-9.