Collaborative Case #010: Managing the Unhappy Presbyopic IOL Patient
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Patient interest in undergoing surgery to reduce the need for glasses and contact lenses continues to grow, as technologies continue to advance. The growth is highest in patients receiving presbyopic IOLs, including trifocal lenses, multifocal lenses, extended depth of focus lenses, and adjustable lenses. Although these lenses can provide excellent visual outcomes, not all patients are ideal candidates. Thus, the preoperative exam is critical for identifying appropriate candidates for refractive IOLs.
In general, it is important to evaluate the ocular surface and perform a preoperative corneal topography and OCT of the macula to ensure that the patient will be an appropriate candidate for a presbyopic IOL.
The Case
In 2021, a 72-year-old female presented with visually significant cataract and no previous history of corneal refractive surgery. She reported some dry eye symptoms, but the slit-lamp exam showed only mild punctate staining and mild meibomian gland dysfunction (MGD). The patient was very interested in a presbyopic IOL. Preoperative testing was performed, and the OCT of the macula was found to be normal. Three tests for measuring corneal astigmatism were performed on each eye: two topographies (Pentacam [Oculus] and Cassini [Cassini]) and biometry (Zeiss IOLMaster 700 [Carl Zeiss Meditec]) (Figures 1 and 2).
There were two reasons for performing these three distinct measurements for astigmatism: the first was to determine whether a toric version of the presbyopic IOL was needed, and the second was to ensure that the astigmatism readings were accurate, because there can be some variability in measurements.
A decision was made to place a Clareon PanOptix Toric IOL (Alcon).
Because the IOL calculation formula predicted a low postoperative degree of astigmatism for the left eye, a nontoric PanOptix IOL was planned. Unfortunately, the finding of a major difference in the Pentacam OS as compared to the Cassini and Argos was not evaluated further.
The most likely cause was inadequately treated dry eye, and the optimal next step should have been to initiate therapy for both dry eye and MGD. This was not done; instead, the patient underwent uncomplicated cataract surgery in both eyes. Unfortunately, the patient was very disappointed with their visual results at the 1-month visit. Dry eye and MGD were identified as the cause, and treatment was initiated with Avenova Lid & Lash Spray (Avenova) and topical steroids. The patient returned, with less-than-adequate vision due to evaporative dry eye. Nondissolvable, silicone punctal plugs were placed and the patient was started on lifitegrast ophthalmic solution 5% (Xiidra, Novartis). Figure 3 shows the patient’s visual acuity 5.5 months after surgery OD and 5 months after surgery OS.
The patient’s dry eye was still not adequately treated, and they continued to complain about their poor quality of vision. The cause continued to be inadequately treated ocular surface disease. The patient did not want to undergo a dry eye procedure (eg, LipiFlow Thermal Pulsation System [Johnson & Johnson Vision Care], the TearCare System [Sight Sciences], Systanee iLux2 [Alcon]) due to cost. We discussed surgical options, and a decision to perform an IOL exchange to a different IOL was confirmed.
The patient was excited to have an IOL exchange to a monofocal IOL, and the decision was made to proceed with surgery in the right eye first. Because there was minimal refractive error, determining the correct power for the new monofocal IOL was very straightforward. The original measurements could be used. An alternative method, the Barrett Rx Formula for IOL exchanges (Figure 4), can be also used to calculate the power of the IOL.
We discussed that in some cases, patients can be quite happy with a monofocal in one eye and a multifocal or trifocal in the fellow eye. The patient’s surgery went well. They achieved 20/25 UCVA OD, and were very happy with their visual outcome. Therapy for MGD and dry eye was continued, and the patient was given 1 year to see if they would remain happy.
Unfortunately, the patient never was able to achieve a level of happiness in their left eye (with the trifocal IOL), and eventually decided to proceed with an IOL exchange to a monofocal IOL. Following the procedure, the patient reported being very pleased with the improved quality of vision.
CONCLUSION
Preoperative evaluation of the ocular surface is a critical step prior to cataract (and refractive) surgery. In this patient’s case, the more optimal management would have been to initiate treatment for dry eye/MGD prior to cataract surgery and to have them return for repeat measurements. This particular patient had dry eye/MGD that could not be completely treated postoperatively, resulting in dissatisfaction with trifocal optics. Thankfully, the switch to monofocal IOLs resulted in a positive outcome.
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ABOUT THIS SERIES
On the path from initial diagnosis to severe disease management, patients may encounter a number of eye care providers. The Collaborative Care Case Series was developed, with guidance from William Trattler, MD, and Diana Shechtman, OD, FAAO, to challenge clinicians' understanding of diagnostic and treatment conventions and advance knowledge of all eye care providers along the continuum.
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