Satisfaction and dysphotopsia in the pseudophakic patient

Satisfaction and dysphotopsia in the pseudophakic patient Nathan R. Welch, MD; Ninel Gregori, MD; Norm Zabriskie, MD; Randall J. Olson, MD ABSTRACT N RE´SUME´ Objective: To examine factors that influence satisfaction after uncomplicated cataract surgery. Design: Retrospective case review and examination of patients. Participants: Sixty-one consecutive patients, seen at the John A. Moran Eye Center, University of Utah School of Medicine, who had uncomplicated cataract surgery from 1 practice and 40 consecutive control patients who met the inclusion criteria and were willing to participate. Methods: Inclusion criteria were best-corrected visual acuity (BCVA) of at least 20/20, without any ocular disease that might affect vision. Patients were given a complete ophthalmic examination, had photos of the intraocular lens (IOL) and capsule taken, and were asked questions about dysphotopsia and satisfaction. A group of patients .65 years old with 20/20 BCVA and without other ophthalmic diagnoses were recruited, asked the same questions, and compared. Results: The only significant correlation with dissatisfaction was dysphotopsia (r 5 0.602, CI 0.42–0.74, p , 0.0001). BCVA, uncorrected visual acuity, posterior capsular opacification, and anterior capsule overlap of the optic were not significantly correlated. The IOL patients were significantly worse for reported glare (p , 0.0001), photophobia (p , 0.0001), and flashes of light (p 5 0.0002), but not for halos. Conclusions: While satisfaction with cataract removal and IOL placement is high, dysphotopsia is the most important contributor to dissatisfaction and is relatively common. Furthermore, these symptoms are much worse than in agematched controls. Research seeking to ameliorate dysphotopsia is clinically important. Objet : Examen des facteurs qui influencent la satisfaction apre`s une chirurgie non complique´e de la cataracte. Nature : E´tude re´trospective et examen de patients. Participants : Soixante une patients conse´cutifs, vus au John A. Moran Eye Center, University of Utah School of Medicine, qui ont subi une chirurgie de la cataracte sans complication dans 1 clinique et de 40 patients te´moins conse´cutifs qui, re´pondant aux crite`res d’inclusion, ont accepte´ de participer. Me´thodes : Les crite`res d’inclusion e´taient la meilleure acuite´ visuelle apre`s correction (MAVAC) d’au moins 20/20 et aucune maladie oculaire qui aurait pu affecter la vision. Les patients ont subi un examen oculaire complet, se sont fait photographier les lentilles intraoculaires (LIO) et la capsule et ont e´te´ interroge´s sur la dysphotopsie et la satisfaction. Un groupe de patients de .65 ans avec MAVAC de 20/20 et sans autre diagnostic oculaire a e´te´ recrute´, soumis aux meˆmes questions et fait l’objet de comparaisons. Re´sultats : La seule corre´lation significative avec l’insatisfaction e´tait la dysphotopsie (r 5 0,602, e´cart de confiance 0,42–0,74, p , 0,0001). Il n’y avait pas de corre´lation significative entre l’acuite´ visuelle (meilleure et sans correction), l’opacification capsulaire poste´rieure et le chevauchement capsulaire ante´rieur sur l’optique. Les patients ayant une LIO e´taient significativement pires quant aux e´blouissements (p , 0,0001), a` la photophobie (p , 0,0001) et aux e´clairs de lumie`re (p 5 0,0002), mais pas pour les halos. Conclusions : Alors que le degre´ de satisfaction apre`s le retrait de la cataracte et l’insertion de la LIO est e´leve´, la dysphotopsie, principale source d’insatisfaction, est relativement commune. Qui plus est, ces symptoˆmes sont beaucoup plus graves que les controˆles associe´s a` l’aˆge. La recherche de moyens pour ame´liorer la dysphotopsie est cliniquement importante.

I

n uncomplicated cataract surgery in a patient with good visual potential our surgical results are quite dependable, and yet some patients are unhappy. Possible causes of dissatisfaction are poor uncorrected visual acuity, posterior capsular opacification (PCO), capsular overlap of the intraocular lens (IOL) optic, and pseudophakic dysphotopsia.1–4 Just how these issues relate to satisfaction and to each other was the subject of this study.

METHODS

From the Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, Utah

Correspondence to Randall J. Olson, MD, Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah School of Medicine, 65 Mario Capecchi Dr., Salt Lake City, Utah 84132; [email protected]

Originally received Sep. 29, 2009. Accepted Oct. 26, 2009 Published online Mar. 8, 2010

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This was an institutional, retrospective case review and examination of patients who had undergone uneventful phacoemulsification and IOL insertion for senile cataracts at the John A. Moran Eye Center, University of Utah School of Medicine. Patients were selected from a single surgeon (Norm Zabriskie). The patients had uneventful phacoemulsification

This article has been peer-reviewed. Cet article a e´te´ e´value´ par les pairs. Can J Ophthalmol 2010;45:140–3 doi:10.3129/i09-266

Satisfaction in pseudophakic patients—Welch et al. for senile cataracts with implantation of a 3-piece SI40NB (Allergan, Inc, Irvine, Calif.) or L161U (Bausch and Lomb Inc, Claremont, Calif.) silicone lens between January 1999 and June 2000. Patients with intraoperative complications, any condition likely to affect visual quality, such as macular degeneration, and placement of the IOL outside of the capsular bag were excluded. Average follow-up length was greater than 24 months after surgery in order to determine patients’ long-term satisfaction with their surgery. The patients’ charts were reviewed for the following data: age, sex, surgical complications, type and power of IOL implanted, ocular condition and visual acuity at follow-up, and any preoperative or postoperative comorbidities. Best-corrected visual acuity (BCVA) had to be at least 20/20 after surgery for patients to be enrolled. Those who had visually significant retinal or corneal disease or a diagnosis of glaucoma or ocular hypertension were also excluded. The surgical technique was identical in all cases and included topical anaesthesia, a clear-corneal incision, capsulorrhexis, lens removal by a divide and conquer technique, cortical clean-up, and insertion of the IOL into the capsular bag using the manufacturer’s inserter (the Silver series unfolder for the SI40NB and the Passport series for the L161U). Both the SI40NB and the L161U used in this study are comparable lenses in that both are second-generation, 3-piece silicone IOLs with rounded edges and 6.0 mm optic size. The selected patients were contacted and invited to participate in the study. Each patient signed a consent form approved by the Institutional Review Board of the University of Utah. This study is compliant with the Health Insurance Portability and Accountability Act. The information was then recorded from the chart, refractive assessment was performed, and logMAR values of BCVA and uncorrected visual acuity (UCVA) were determined. The patient was examined (slit-lamp examination and dilated IOL and fundus examinations). Retro-illumination photographs of the IOL were then taken. The patient was also asked questions dealing with dysphotopsia: 1. Do you experience glare when looking into light (ranked no, hardly ever, more often than not, or always)? 2. Do you experience sensitivity to light (ranked no, hardly ever, more often than not, or always)? 3. Do you see flashes of light (yes or no)? and 4. Do you see halos around lights (yes or no)? Overall satisfaction with vision after surgery was ranked as very satisfied, satisfied, neutral, dissatisfied, and very dissatisfied. Consecutive patients seen in our clinic who were over 65 years of age with 20/20 BCVA and no diagnosis of cataract or retinal, optic nerve, or corneal pathology were asked the same dysphotopsia questions. PCO was determined by use of the estimation of PCO software from the retro-illumination photograph when

the capsule was intact (had no laser capsulotomy). Anterior capsule overlap (degree of overlap was measured from the photographs by using a protractor) was also determined from the retro-illumination photographs when the entire IOL edge or capsular overlap was visible. Any patient found to have corneal, retinal, or optic nerve disease at this visit was also excluded. Statistical analyses were performed using Microsoft Office Excel 2003. Pearson product moment correlation coefficients and r 2 values were used for all correlation calculations. Simple Interactive Statistical Analysis, an online tool provided by Quantitative Skills Consultancy for Research and Statistics, was used to calculate 2-tailed Student’s t tests for comparing means between the 2 IOL group types. To compare sex ratios, x2 analysis was used. The rest of the comparisons were univariate analyses. Using a Bonferroni correction for multiple comparisons, p values less than 0.002 were considered to be statistically significant. A dysphotopsia score was calculated by adding the scores for all 4 questions where no equals 0, hardly ever equals 1, more often than not equals 2, and always equals 3. For the two yes and no questions, no equals 0 and yes equals 2. Satisfaction was scored as very satisfied equals 0, satisfied equals 1, no change since before surgery equals 2, dissatisfied equals 3, and very dissatisfied equals 4. RESULTS

Sixty-one patients were included in the study. The 2 IOL groups (L161U, n 5 27, and SI40NB, n 5 34) showed no significant differences in any outcome or demographic category and were therefore analyzed as a single group when outcomes were considered (Table 1). The only significant positive correlation found was between satisfaction and the amount of dysphotopsia (r 5 0.602, p , 0.0001). UCVA, BCVA, PCO, and anterior capsule overlap did not significantly correlate with satisfaction (Table 2). Forty control patients were compared with the pseudophakic patients and found to have significantly fewer Table 1—Comparison of L161U lens and SI40NB lens groups L161U

SI4ONB

Category of comparison

n

Mean

n

Mean

p value

Mean (SD) patient age, y

27

69.9 (10.5)

34

74.7 (8.7)

0.056

Sex (M/F ratio)

27

14/14

34

20/16

0.659

Mean (SD) follow-up, days

27

799 (82)

34

811 (171)

0.715

Mean (SD) dissatisfaction score*

27

1.04 (1.4)

34

1.06 (1.8)

0.960

Dysphotopsia

27

4.04 (3.3)

34

4.56 (3.7)

0.558

PCO

21

0.38 (0.56)

25

0.14 (0.21)

0.080

UCVA, logMAR

27

0.22 (0.26)

34

0.18 (0.16)

0.483

BCVA, logMAR

27

0.08 (0.21)

34

0.04 (0.14)

0.392

AC overlap

16

330u (56)

21

337u (47)

0.690

*The lower the score, the less the dissatisfaction. Note: PCO, posterior capsular opacification; UCVA, uncorrected visual acuity; BCVA, bestcorrected visual acuity; AC, anterior capsule.

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Satisfaction in pseudophakic patients—Welch et al. symptoms regarding glare (p (p , 0.0001), light flashes (p (p 5 0.36; Table 3).

, 0.0001), photophobia 5 0.0002), but not halos

DISCUSSION

This study examined dysphotopsia and satisfaction in patients who had been the recipients of the type of IOLs already believed to be the least likely to create significant dysphotopsia, being 6.0 mm, silicone optics with low refractive index and rounded edges.2 Nonetheless, dysphotopsia was found to be quite frequent when patients were queried. Furthermore, we had no record that any of these patients had ever complained about dysphotopsia. Despite this, satisfaction was generally good, 59/64 being satisfied or very satisfied. The pseudophakic patients, however, reported significantly more glare, light sensitivity, and light flashes than a group of patients older than 65 whose eyes were phakic. In fact, flashes of light were reported in 30% of the pseudophakic patients and in none of the controls, suggesting that many of these complaints are quite IOL specific. While a number of factors that could influence satisfaction after cataract extraction and IOL placement were studied, only dysphotopsia was found to have a significant correlation, and this correlation was both strong (r 5 0.602) and highly significant (p , 0.0001). So it is our conclusion that in healthy patients with uncomplicated cataract surgery, dysphotopsia is clearly our most important source of dissatisfaction and is rarely associated with aging with no or minimal cataract. For this reason, better methods to eliminate this problem should be explored. We spend enormous resources to get our biometry right and push for refractive perfection, and yet a problem largely Table 2—Correlation of outcome measures with dissatisfaction Outcome

n

r

r2

p value (2-tailed)

CI (95%)

Dysphotopsia (05none)

61

0.6017 0.3620

,0.0001

0.418, 0.738

BCVA, logMAR

61

0.2593 0.0672

0.040

0.012, 0.476

UCVA, logMAR

61

0.2030 0.0412

0.111

20.047, 0.429

PCO, EPCO score

46

20.0128 0.0002

0.933

20.302, 0.279

Capsular overlap on IOL, degrees

37

0.2610 0.0681

0.119

20.069, 0.539

Note: BCVA, best-corrected visual acuity; UCVA, uncorrected visual acuity; PCO, posterior capsule opacification; EPCO, estimation of posterior capsule opacification; IOL, intraocular lens.

Table 3—Comparison of visual phenomena of 61 pseudophakic patients and 40 control* patients Score{ (mean [SD]) or % Yes Pseudophakic

Phakic

p value (2-tailed)

Glare

1.08 (0.92)

0.18 (0.50)

,0.0001

Light sensitivity

1.02 (1.00)

0.23 (0.58)

,0.0001

Light flashes

30%

0%

0.0002

Halos

14%

8%

0.36

Phenomenon

*Patients over the age of 65 with 20/20 best-corrected vision and without a clinical diagnosis of cataract or any other visually significant eye condition. { No 5 0, hardly ever 5 1, more often than not 5 2, always 5 3.

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beyond our control (pseudophakic dysphotopsia) is much more important in the final outcome. Other factors, such as UCVA, BCVA, PCO, and IOL optic capsular overlap did not significantly correlate with satisfaction, although with greater study power they might have. Even if they did, dysphotopsia was clearly more important. In this era of premium IOLs, patient satisfaction has taken on new importance. While biometry results and treatment of pre-existing astigmatism are often stressed as the critical factors in patient satisfaction, unwanted images are not an uncommon issue for the unhappy patient. Multifocal IOLs often increase dysphotopsia over monofocal IOLs as a result of either the refractive or diffractive rings on the IOL, so dysphotopsia may be an even stronger cause of dissatisfaction among premium IOLs. Furthermore, rounded edge, 6 mm optic, silicone IOLs are often used in IOL exchanges for patients unhappy with dysphotopsia, so the problem may be greater with monofocal IOLs commonly used today.2,4 The weaknesses of this study include the fact that common forms of dysphotopsia (e.g., temporal darkness) were not queried. The simplicity of the questions leaves little doubt about what the patient is experiencing, and the clear differences between the pseudophakic patients and the controls ensure that the questions do validly differentiate them for at least 3 of the 4 queries. Concerning temporal darkness, this is an exceedingly rare complaint for patients with round-edge silicone IOLs, so there was no expectation of a positive response to such a query. This work needs to be updated with present-generation acrylic and silicone IOLs to determine how the results may differ. Our expectation is that dysphotopsia would be an even greater cause of dissatisfaction. CONCLUSIONS

This study illustrates that the general level of patient satisfaction regarding cataract removal and IOL placement, while high, is affected more by dysphotopsia than any other parameter studied, including UVCA, BCVA, PCO, and anterior capsular overlap of the IOL optic. Furthermore, for glare, light sensitivity, and light flashes the complaints were significantly greater than in a group of patients with phakic eyes and 20/20 vision who were older than 65. Although the study may not have had the power to detect more subtle correlations with these other factors (n 5 61 patients), the correlation between dissatisfaction and dysphotopsia was strong (r 5 0.602) and highly significant (p , 0.0001). The findings were obtained with IOLs often used for exchange for patients with persisting and severe dysphotopsia (6.0 mm silicone optic with rounded optic edges), so the problem may be more severe for IOLs commonly used today. Pseudophakic dysphotopsia is an important contributor to dissatisfaction and deserves more attention to ameliorate this problem.

Satisfaction in pseudophakic patients—Welch et al. Supported in part by a grant from Research to Prevent Blindness, Inc., New York, N.Y., to the Department of Ophthalmology and Visual Sciences, University of Utah. Randall J. Olson is a consultant with Advanced Medical Optics.

REFERENCES 1. Smith SR, Daynes T, Hinckley M, Wallin TR, Olson RJ. The effect of lens edge design versus anterior capsule overlap on posterior capsule opacification. Am J Ophthalmol 2004;138: 521–6. 2. Tester R, Pace NL, Samore M, Olson RJ. Dysphotopsia in phakic and pseudophakic patients: incidence and relation

to intraocular lens type. J Cataract Refract Surg 2000;26: 810–6. 3. Farbowitz MA, Zabriskie NA, Crandall AS, Olson RJ, Miller KM. Visual complaints associated with the AcrySof acrylic intraocular lens. J Cataract Refract Surg 2000;26: 1339–45. 4. Wallin TR, Hinckley M, Nilson C, Olson RJ. A clinical comparison of single-piece and three-piece truncated hydrophobic acrylic intraocular lenses. Am J Ophthalmol 2003;136:614–9.

Keywords: dysphotopsia, intraocular lens, glare

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