Managing an Unhappy Pseudophakic Patient

Patient questionnaires can help determine patient satisfaction.

Managing an Unhappy

Pseudophakic by Hazlin Hassan Patient

While the vast majority of pseudophakic patients are happy with the quality of vision following surgery, occasionally there are patients who are dissatisfied. To better manage these patients, renowned experts shared tips during a session at the 37th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2019).

When 20/20 Does Not Cut It

complications — sometimes even patients with 20/20 vision can be unhappy.

“In Sweden, many ophthalmic departments take part in reporting postoperative data to the national cataract register (NCR),” said Dr. Maria Kugelberg of St. Erik Eye Hospital, Sweden.

Around 10% of patients experience no benefits from surgery, according to reports from the Swedish NCR. from the preoperative stage to three months postoperative, 90.1% were satisfied, 2.2% were neutral and 7.7% were dissatisfied,” added Dr. Kugelberg.

According to the reports, men were 1.3 times more likely to be satisfied with their vision than women. Patients without ocular comorbidity were 1.8 times more likely to be satisfied, while patients with a second eye surgery were twice as likely to be satisfied.

Patients with ocular comorbidities reported higher incidences of dissatisfaction. Those with glaucoma

were twice as likely to be dissatisfied, while patients with macular degeneration were 2.8 times more likely to be unhappy.

Meanwhile, patients with both glaucoma and macular degeneration were 5 times more likely to be dissatisfied.

A survey of 1,239 patients also showed that the majority of patients (59%), did not obtain new distance spectacles postoperatively, while 41% did. A total of 68% said they could see well enough without glasses; 14% could see well with their old spectacles;13% said they planned to obtain a new pair; and 2% cited economic reasons for not purchasing new spectacles.

Dr. Kugelberg concluded that if a patient had low disability or high visual acuity before surgery, the patient is “too healthy” and surgery can wait. On the other hand, if the patient has other eye diseases that make improvement unlikely, it’s also better to wait before scheduling surgery, as they are too sick.

What Makes Patients Unhappy?

Prof. Konrad Pesudovs from the University of New South Wales in Sydney, Australia, and the Anglia Ruskin University in Cambridge, U.K., said that patients are usually concerned with 12 domains of ophthalmic quality of life. These are activity limitations caused by loss of vision and include: driving, ocular comfort symptoms, visual symptoms, general symptoms, emotional wellbeing, health concerns, convenience, social participation, economic concerns and coping.

While cataract surgery aims to reverse these activity limitations, some 7.4% of patients still suffer from limitations after cataract surgery.

Prof. Pesudovs concluded that the key question for new intraocular lens (IOL) design is whether or not the balance of near vision gains and the loss of quality of vision leads to patient satisfaction.

Properly managing visual expectations can turn an unhappy patient into a happy one.

All is Well Until the IOL Dislocates

According to Tel-Aviv University Ophthalmology Prof. Ehud Assia, the late dislocation of a posterior chamber intraocular lens (PC-IOL), which occurs more than three months postoperatively, is not uncommon.

There is increasing incidence for cases like this in older patients, due to a longer lifespan and longer follow-up.

Cumulative incidence of late dislocation of PC-IOL was reported at 0.1% at 10 years, 0.2% at 15 years, 1.0% at 20 years, and 1.7% at 25 years. This shows that subluxation of a PC-IOL is not uncommon and may occur many years after implantation.

Options include surgical management, changing the IOL or repositioning it. “Excellent results are usually achieved using modern techniques and instruments,” Prof. Assia concluded. “Perfection does not exist,” she noted. “Neither does zero risk.” Therefore, it is important to inform the patient what each lens or surgical procedure is capable of achieving to avoid disappointment and create reasonable expectations.

For some patients, the goal is perfection after surgery. But what does perfection mean?

According to Dr. Beatrice CochenerLamard from the ophthalmology department at Brest University Hospital in France, this means spectacle independence at all distances and not even thinking about their eyes.

It’s All About Managing Expectations

Before the surgery, the patient needs to know the advantages, limits and potential complications of the procedure. Sources of unhappiness can include inadequate visual acuity, double vision or multiple halos, ghost images, glare, photophobia, comet tails and dysphotopsia.

These phenomena can be checked using questionnaires or with refraction, visual acuity, pinhole and/or slit lamp examination. In these cases, Dr. Cochener-Lamard suggested that patients wait for at least three months to allow for neuroadaptation and healing.

Editor’s Note:

The 37 th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2019) took place from September 14 to 18 at Pavilion 7, Paris Expo, Porte de Versailles, Paris, France. Reporting for this story also took place at the ESCRS 2019.