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    Managing unhappy presbyopia patients

    Listen, counsel before taking action; identify cause


    Treatment for dry eye will depend on the cause and its severity. It may include lubricants, topical and oral anti-inflammatory medications, thermal pulsation, environmental and behavioral modifications, punctal plugs, and omega-3 fatty acid supplementation.

    Because refractive error is a common cause for dissatisfaction among presbyopia-correcting IOL patients, surgeons who are offering this technology should be prepared to perform excimer laser enhancement procedures. Dr. Berdahl noted that in his practice, all patients are counseled preoperatively about the possibility of having another procedure, and the cost of a refractive touchup is included in the premium package.

    Posterior capsule opacification (PCO) is another common issue underlying vision complaints among patients with a presbyopia-correcting IOL. Because IOL exchange is much more difficult once the posterior capsule is open, surgeons should be absolutely certain that PCO is a patient’s problem and that treating it is likely to make the patient happier with his or her vision.

    Positive dysphotopsia, i.e., glare and halos, is another issue that patients may complain about after presbyopia-correcting IOL surgery.

    Dr. Berdahl said that even though the risk can be mitigated by making sure that dry eye is adequately treated and by excluding patients who have high levels of corneal higher-order aberrations or irregular astigmatism, all patients receiving a multifocal or extended depth of focus IOL should be counseled about the potential for these visual symptoms.

    “I tell my patients that by choosing these lenses, they are trading some visual quality for an increase in flexibility through decreased dependence on glasses,” he said. “I say they will likely have some glare and some halos and that the brain usually learns to adapt to these issues, just as it learns to filter out the shadow created by the edge of their frames or their nose when they look through their glasses.”

    At the same time, however, he counsels patients that there is a small chance that they will find the problems persistently bothersome to the point where management would involve removing the presbyopia-correcting IOL and replacing it with a standard monofocal lens.

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