LFR: Can the Vitreous Help Explain the Unhappy Postop Cataract Patient?
21 December 2017 / Dr. Paul I. Singh
“Can the Vitreous Help Explain the Unhappy Postop Cataract Patient?”
Our cataract patients’ expectations have steadily increased as our surgical technique and IOL technology has advanced over the years. As a profession, we have focused a great deal of attention on the smallest detail during the entire process; pre-op, (including biometry, topography, OCT), to intraoperative tools and techniques (such as femtosecond assisted surgery, intra op aberrometry, and premium IOLs), to postop drop and capsule management. This increased attention-to-detail has truly helped us achieve incredible outcomes and resulted in more highly satisfied patients. Unfortunately, not all of our patients are satisfied post-cataract surgery, and sometimes it has nothing to do with our surgical technique. Outside of the usual causes of unsatisfied postop patients (residual refractive error, dry eye, and undiagnosed retinal pathology), the vitreous can actually be a source of agony for some of these patients.
Does this scenario sound familiar? You perform an amazing efficient cataract surgery, with minimal phase energy while implanting a premium IOL. Postoperative month one in-office VA is 20/20 distance and J1 near, but the patient is unhappy: “you” created a large cloud that comes in and out of their vision, which makes it difficult for them to drive and read. The patient actually states: “Doc, I am worse off than before surgery.” This patient has already told multiple friends how unhappy they are.
Your first reaction is: “What can this patient be complaining about? They are seeing so well on the chart!” You check the cornea, the capsule, and retina, but everything looks clear and healthy. So what could be the issue? Well, what about the vitreous? It’s easy to miss opacities in the vitreous since most of us are not looking for issues in that space. After some time, you look closely in the vitreous see a large amorphous cloud that traverses in and out of the center. So now what do you tell the patient? Although it is normal and common to occur at any time of life, when floaters form or are more noticeable after cataract surgery, it can minimize the postoperative “wow” factor and decrease patent satisfaction. “The surgery caused this.” It’s really tough having to tell a patient like this to “just deal with it.” The surgeon in this case may have to deal with an unhappy patient for a long time, since many of these patients do not neuro-adapt to these types of floaters.
And by the way, the surgeon outlined in the scenario above was me, adapted from a situation I was dealing with five years ago, before I adopted YAG laser floater treatment in my practice.
Since 2013, I have performed Laser Floater Removal on thousands of patients. Approximately 60% of these patients have been postoperative cataract patients, and many of them with multifocal IOLs. These patients are often very frustrated since they paid a significant amount of money to achieve spectacle independence with the expectation of high quality of vision. Using ray tracing via the iTrace device (Tracey Technologies), we have now demonstrated the impact vitreous floaters can have on quality of vision. We recently presented data at ASCRS 2017 demonstrating improved HOA and MTF post laser floater treatment. Some of the greatest improvements in HOA and MTF and corresponding patient satisfaction is seen in multifocal IOL patients post laser floater treatment. We now have a case series of over 30 patients with multifocal IOLs complaining of distortion in vision, difficulty reading, and significant glare not attributable to any other pathology besides the vitreous opacities that have undergone treatment with Laser Floater Removal. Subjective symptomology has greatly improved post treatment as well, as objective quality of vision assessment using the iTrace device.
Since patient satisfaction is often our main objective, and the goal for our cataract surgery outcome, I now approach floaters not as a nuisance, but rather another pathology that can decrease my chances of achieving that “20/Happy” patient. With new technology, allowing for relatively safe and effective treatment of floaters, I am now more diligent in educating patients who have vitreous opacities at their pre-op exam: I warn them they might notice floaters post-cataract surgery, and thereby recommend that they may need to undergo a laser floater treatment if they develop floaters or start to notice them. This has been a paradigm shift for my practice; treating floaters as a condition that has an impact on patient satisfaction that warrants proper education and attention.