BLOG: Plan ahead for unsatisfactory outcomes
Results with contemporary extended depth of focus IOLs for the correction of presbyopia are excellent, but that doesn’t mean surgeons can get complacent. In my practice, about 92% to 94% of patients are within 0.5 D of plano postoperatively, on both astigmatism and spherical equivalent.
One might think that the enhancement rate would closely correlate to the percentage of patients with more than 0.5 D of error — in other words, about 6% to 8%. However, our actual enhancement rate is much lower, about 1% to 2%. That’s because some patients with minor residual error will nonetheless be satisfied with their vision and not desire enhancement. In other cases, we can manage the binocular outcome by changing our refractive target or IOL selection for the fellow eye, based on the first eye postoperative outcome.
Ironically, these excellent results make it even more important that surgeons think carefully about how to handle the infrequent need for enhancement.
Surgeons must know in advance and clearly explain to referring doctors and patients how enhancements will be handled. Will you perform an IOL exchange, laser vision correction or relaxing incisions? Will you charge for enhancements? If you don’t have an excimer laser, who will perform laser vision correction on your behalf? I strongly encourage surgeons who are going to implant toric or presbyopia-correcting IOLs to become comfortable with limbal relaxing incisions (LRIs) for astigmatism, at a minimum. LRIs are relatively easy to learn and can make the difference between an unhappy 20/30 patient and a happy 20/20 one.
Disclosure: Yeu reports she is a consultant/adviser for Alcon, Allergan, ArcScan, Bausch + Lomb/Valeant, Bio-Tissue, BVI, i-Optics, J&J Vision, Lensar, Kala Pharmaceuticals, Novartis, Ocular Science, Ocular Therapeutix, Ocusoft, Omeros, Science Based Health, Shire, SightLife Surgical, Sun, TearLab, TearScience, Veracity and Zeiss; does research for Alcon, Allergan, Bausch + Lomb, Bio-Tissue, i-Optics, Kala and Topcon; and has an ownership interest in ArcScan, Modernizing Medicine, Ocular Science, SightLife Surgical and Strathspey Crown.