Managing a difficult situation

How to satisfy patients with complaints of post-op haloes and glare

If a spontaneous tear in the capsule occurs, extending into the periphery, the stained capsule next to a white cataract is similar to the blue-white-blue of the Argentinian flag.

We have discussed dysphotopsias several times in previous eyeCONNECTIONs columns. Glare and haloes have been an anticipated occurrence with multifocal lenses. However, the occurrence in monofocal lenses has given all of us fits, especially when the YAG laser doesn’t eliminate the problem. Thanks to several contributors who are profiled in this month’s column, I was enlightened on how to better handle this dilemma.

Two months ago, a 35-year-old male presented with a leucokoric cataract in the right eye (no trauma history).The left eye was 20/20 uncorrected with slight posterior capsule haze starting. We scheduled the case.
 I filled the chamber with Healon5 (Abbott Medical Optics, AMO, Santa Ana, Calif.), which is my preferred viscoelastic in these types of cataracts. I then painted the anterior capsule with Vision Blue (trypan blue, Dutch Ophthalmic Research Center, Zuidland, The Netherlands). I punctured the central anterior capsule with a 25-gauge cystotome and make a slight move radially. Within two seconds … I noted an Argentinian Flag Sign. The plan to implant a Crystalens HD (Bausch & Lomb, Rochester, N.Y.), was aborted. The tear went very peripherally to the lens equator but not to the posterior capsule. I left the anterior capsulotomy as a vertical slit, operating temporally, and took a deep breath. I carefully performed irrigation and aspiration and left an intact posterior capsule with a sulcus-fixated three-piece silicone IOL well centered, which I left anterior to the anterior capsule leaflets. 
The first day post-op, the patient had 20/20 uncorrected distance vision (yes, he was disappointed). He was semi-happy for the first three months but then complained of hazy vision as the anterior/posterior capsules fogged and dropped his vision to 20/40 but foggy.
Before you read on, think about what you would have done at this point.
Yes, I yagged the posterior capsule centrally 4 mm and created a larger anterior capsule opening so that no cloudy capsule would be seen in an undilated pupil.
One week post yag, the panicked and slightly angry young man appeared ready for jousting at the slitlamp. His uncorrected distance vision again was 20/20, but the patient complained of severe nighttime glare with haloes. The 4-mm undilated pupil was completely clear of any opacities. The IOL was well-centered, with no edge seen in the undilated pupil. The results from the dilated exam were normal, with no anterior/posterior segment inflammation. 
Advice, dear colleagues?
Jay Novetsky, M.D.
Sterling Heights, Mich.

Younger patients with fewer life experiences tend to have unrealistic expectations, and this patient is comparing the outcome in his surgical eye to a normal young eye with accommodation. The surgical eye will never be as good. He (and you) will need to “grieve” the outcome. The classic phases are denial, bargaining, anger (where he is now), depression, and acceptance. I suspect you used an aspheric IOL. Haloes are usually spherical aberration. I suggest you do a wavefront analysis and measure the spherical aberration (SA). Lens tilt usually causes astigmatism and coma, and this can also be experienced as unwanted night vision symptoms. Ocular surface disease can do it as well. Once you make the diagnosis, you can treat. In many cases, a smaller pupil helps. It would be good to measure the mesopic and scotopic pupil size. Try Alphagan (Allergan, Irvine, Calif.) and pilocarpine 0.5% to see what it does to the symptoms. Stay with the patient, but in some cases a second opinion helps, especially when the consultative ophthalmologist tells the patient the surgery was beautifully done in a very difficult eye and supports you through to the best possible outcome. Choose you consultative ophthalmologist wisely.
Richard Lindstrom, M.D.
Minneapolis

The IOL used was a Bausch & Lomb (Rochester, N.Y.) LI61AO, which is designed to at least not worsen SA. I did start the patient on artificial tears and one drop of pilocarpine 0.5% just before nightfall, with a two-week return to clinic for a reevaluation. Assuming his refraction is near plano and we obtained a wavescan analysis, even if he had high levels of SA, how could you treat him without a refractive error? Also, is there any advantage to Alphagan instead of pilocarpine? Assuming no significant brow ache from pilocarpine, is long-term miosis safer with Alphagan?
Jay Novetsky, M.D.

For me, it is still important to make the diagnosis of the etiology of the symptoms. I find most patients appreciate it as well. So if we can say, “You have high spherical aberration or high coma,”then we can explain the symptoms. Regarding treatment, Alphagan works by reducing mesopic/scotopic dilation, while pilocarpine causes constriction. For me it is how small a pupil the patient needs and how well they do with the two drops. I often try both and explain how they work. Once we have a diagnosis, we can try for a treatment plan. There are treatment plans that can correct most optical problems, including contact lenses, two-stage laser treatments, and IOL exchange. It may be that the risk/benefit ratio will not justify further treatment. This is common, but at least the patient will know what the options are, and that is part of the process for the patient coming to acceptance.
I am an advocate of the “Sorry Works” approach to the dissatisfied patient. You can look it up on the Web if interested. Their research shows the dissatisfied patient wants to know: 1. What happened and why they have a problem. 2. That we the physician/surgeon are sorry it happened. Basically, patients want to know that we care and will do all we can to help them recover. 3. What the treatment possibilities are to mitigate the problem and the risks behind various treatments. 4. What can and is being done to reduce the chance this problem will occur for others. (Yes, the patients often care deeply about the outcomes of future patients). Knowing these four facts and the grieving process has helped me as a consultative ophthalmologist get many patients and surgeons through tough situations and avoided a lot of malpractice litigation.
Richard Lindstrom, M.D.

I agree with trying Alphagan and, if needed, pilocarpine 0.5 to 1% to see if that helps with the symptoms. 
The things I would look for that could be treated would be residual refractive error (night myopia, too; you can re-refract him dilated), ocular surface disease, and consider expanding the YAG opening.
I would explain to him that this was an abnormal eye with an advanced cataract when the other eye had no such changes. Often eyes like this are abnormal in more than one way, and the glare may be something inherent in the eye or related to the implant, but the implant he has is one least likely to cause such symptoms, and your implant options were limited given the situation..
I’d also be grateful that the patient doesn’t have the same complaints with a Crystalens HD, for which he paid an upcharge. 
I think the patient should be grateful that he has an excellent surgeon and an excellent outcome. When you survive a difficult surgical situation like this and bring the patient back from blindness to 20/20, your first inclination may be to try to remind the patient how fortunate he is to be where he is. Most patients, however, respond best when you do the following:
1. Listen with empathy, showing you care and take his complaint seriously.
2. Provide an explanation for the problem.
3. Come up with a treatment plan consistent with your explanation.
4. See them back and demonstrate some improvement to them, even if it’s small.
I would also absolutely consider a second opinion from someone wise and trustworthy. If he goes elsewhere on his own, they will not be aware of the situation that existed in the OR, and they may tell him that his surgery was less than ideal. If you arrange an opinion for him with someone who is apprised of what happened in the OR, you will be much better served.
Steven Safran, M.D.
Lawrenceville N.J.

Congratulations on a beautiful result in a stressful situation. You were probably forearmed with the correct sulcus lens power for such a great distance uncorrected visual acuity.
I can see the concern is legal and not medical. I would tell him that IOLs are a marvelous technology but are a human creation and as such cannot be perfect and may display aberrations under certain situations. I would try miotics first.
Of course, this case raises some questions:
1. Do we now have to tell all patients that IOLs are imperfect and that no guarantee of aberration-free vision is possible?
2. Do we now have to tell all premium IOL patients that if complications occur we may have to fall back on a conventional lens? Probably not a bad idea. I certainly do so in high-risk cases (I think always), but maybe in all cases is best.
3. Tort reform now. Apparently all a patient has to do is invent symptoms that are impossible to demonstrate objectively (by definition) or with a determinable cause that can be demonstrated in order to win a jackpot in our legal system. Obviously the lawyers know this when it comes to pain symptoms (e.g., whiplash). I wonder if word is getting around that “glare” is a great handle for a lawsuit. See: www.onlinelawyersource.com/news/lasik-suit.html
Disabling, postoperative, and impossible to verify.
Mitchell Gossman, M.D.
St. Cloud, Minn.

The crystalline lens of the younger /youngish patient is far more sophisticated than anything we’re presently able to offer as a replacement. I have explanted more than a few IOLs for other physicians where I thought the surgery was flawless, with a near perfect refractive outcome, yet the complaints were bitter and the patient angry.
If you can, Dr. Lindstrom’s suggestion of measuring the aberration profile of either the anterior cornea or the whole eye may offer some additional insights. I recently saw a 50- year-old who had perfectly executed cataract surgery with a Tecnis multifocal IOL (AMO) after hyperopic LASIK. The anterior corneal spherical aberration was around
–0.6 microns. He felt that night vision was worse than before lens extraction. I’m considering an exchange for a spherical monofocal IOL.
For your patient, since the aberration profile will improve with a decrease in pupil size, if the complaints are aberration-driven, Alphagan or weak pilocarpine should almost immediately improve things. If the complaints are the same with a smaller pupil, you’ll have to work the problem in a more in-depth manner like we do with a multifocal, starting with the anterior cornea and working posterior. However, at the end of the day it may just turn out that he’ll have to adapt.
Good luck. At the onset, these are always an emotional drain.
Warren Hill, M.D.
Mesa, Ariz.

Editors’ note: Dr. Lindstrom has financial interests with Abbott Medical Optics (Santa Ana, Calif.), Alcon (Fort Worth, Texas), and Bausch & Lomb (Rochester, N.Y.), among others. Drs. Novetsky, Safran, Gossman, and Hill have no financial interests related to their comments.

If you are not following these threads on the ASCRS electronic mailing list, you are missing the latest developments in cataract, refractive, glaucoma, and business practices. To join ASCRS eyeCONNECT, where you can receive and exchange the most current thoughts about the hottest topics in ophthalmology, search archives, and more, log onto www.ascrs.org or www.eyespacemd.org.

Contact information

Gossman: mgossman@esppa.com
Hill: k7wx@earthlink.net
Lindstrom: rllindstrom@mneye.com
Novetsky: chozeh@comcast.net
Safran: safran12@comcast.net

ABOUT THE AUTHOR

J.E. “Jay” McDonald II, M.D., is the EyeMail editor. He is director of McDonald Eye Associates, Fayetteville, Ark. Contact him at 479-521-2555 or
mcdonaldje@mcdonaldeye.com.