ENHANCEMENTS

AFTER CATARACT
SURGERY

JORGE L. ALIO; AHMED A. ABDELGHANY; ROBERTO FERNENDEZBUENAGA

ABSTRACT
AND
INTRODUCTION

ABSTRA
CT

INTRODUCTION
Cataract removal with IOL implantation one of the most frequently
performed surgical procedures in clinical practice.

Modern microsurgical techniques, new IOL technologies, sophisticated

biometric methods and advanced methods of IOL power calculation

HIGH-QUALITY VISION

In a multinational cataract surgery population consisting of over

360.000 cataract extractions:

92,6% achieved improved corrected distance visual acuity

5.7% were unchanged
1,7% had worse corrected distance visual acuity after surgery.

 Advances in small incision surgery have enable cataract surgeon

to progress from being concerned primarily with the well
tolerated removal of the opaque crystalline lens to a procedure
refined to yield the best possible postoperative refractive result.

Refractive considerations are integrated in modern cataract

surgery, and emmetropia the aim in the majority of cataract

cases today in a recent report analyzing refractive data of
over 17.000 eyes after cataract surgery emmetropia was only
achieved in 55% of eyes in which it was targeted

 Residual postoperative astigmatism is not uncommon.

A physiological astigmatism of up 1 D either with or against the rule

may be useful to increase the depth of focus under routine
conditions, and may increase the quality of vision in daily life.

Astigmatism of up to 1 D may also be considered a physiological

measure to reduce uncorrected presbyopia for eyes with intact retina

and optic nerve.

Uncorrected corneal astigmatism pseudophakic eyes significantly

affects through-focus performance of presbyopia-correcting IOLs.

Although multifocal IOLs increase depth of focus this

benefit diminishes when over 0.75 D of astigmatism remains

uncorrected.

 The use of multifocal IOLs has recently become a popular alternative to

monofocal IOLs in patients who do not want to wear spectacles after cataract
surgery or after refractive lens extraction.

Image quality in patients implanted with multifocal IOLs diminishes when over

0.75 D astigmatism remains uncorrected They may also suffer from a severe
decrease in quality of vision due to blurred vision, glares, halos, photophobia
and diplopia, and can benefit considerably from an IOL exchange.

This leads to a significantly improved corrected visual acuity, both for distance
and near vision.

 The main drawback of multifocal IOL exchange to a monofocal

IOL is the reduction in spectacle independence for reading.

When spectacle independence is important, monovision with a

precalculated myopic deviation may be also an option.

Despite new advances in cataract surgery, unsatisfactory visual

outcome, mainly due to residual refractive error, occasionally

occurs. This has led us to review the causes of patients
dissatisfaction after cataract surgery and the possible approaches
for enhancement after cataract surgery.

CAUSES OF UNSATISFACTORY
VISUAL OUTCOME AFTER
CATARACT SURGERY

RESIDUAL REFRACTIVE
ERROR

The most frequent complication

following cataract surgery

MULTIFOCAL INTRAOCULAR LENS VISUAL

EFFECTS
However, even if emmetropia is reached, patients implanted with

multifocal IOLs may suffer from a severe decrease in quality of

vision due to blurred vision, glare, halos, photophobia and diplopia.

The most important parameter regarding quality of vision

probably the orientation of the photoreceptors (Stiles-Crawford

effect) the parameter of which is even more difficult to objectify
preoperatively and postoperatively

Residual ametropia and astigmatism, posterior capsule opacification

and a large pupil were the three most significant etiologies

INTRAOCULAR LENS MALPOSITION

Tilt and decentration of IOLs result in defocusing, astigmatism and
wavefront aberration.

It may occur early postoperatively due to inadequate capsular support or

later secondary to capsule contraction and capsulorhexis phimosos

Late IOL dislocation remains anunusual complication after cataract surgery

Pseudoexfoliation has always been the most recognized predisposing
factor for late dislocation, and a recent series highlighted that high myopia
is an important risk factor for the late in-the-bag serious IOL dislocation
after uneventful cataract surgery.

Furthermore, dislocation in high myopia occurred at a younger age than in

pseudoexfoliation, hence affecting patients with higher visual demands.

ENHANCEMENTS (TOUCH
UP) AFTER CATARACT
SURGERY
There are different methods that can be used
to resolve these unsatisfactory situations

When a secondary procedure is performed for

the correction of refractive error
REFRACTIVE ENHANCEMENT

When it is performed for other visual problems

NONREFRACTIVE ENHANCEMENT

ENHANCEMENTS (TOUCH UP) AFTER

CATARACT SURGERY

TORIC INTRAOCULAR LENS

ROTATION
be used when excess manifest refractive cylinder leads
Can
to an unacceptable level of unaided vision in a patient after
toric IOL implantation.

IOL rotation should be the preferred choice if the surgeon:

Expects the rotation to reduce the manifest refractive cylinder to an acceptable

level,

Knows how much and in which direction to rotate the IOL

Capable of performing the desired rotation

In some cases, IOL rotation will not result in a significant

reduction in the which case nonlens ocular residual

astigmatism is likely to be present unless there has been an
incorrect selection of the toric IOL LASIK to target
plano and correct for the refractive surprise.

 LASIK has proved to be the most accurate procedure to correct residual

refractive error after cataract surgery.

IOL-based surgical procedures are less predictable and should be selected

according to the problem.

IOL exchange is preferred in patients implanted with multifocal IOLs, suffering

from a severe decrease in quality of vision.

Piggyback IOLs are preferred mainly for the correction of high residual
refractive error after cataract surgery when LASIK is not available.

Toric IOL rotation can be used for excess residual manifest refractive cylinder.

CONCLUSI

KEY POINTS
LASIK proves to be a viable, noninvasive and the most accurate procedure to
correct ametropia after cataract extraction with IOL implantation.

Piggyback IOLs should be used mainly for the correction of high residual
refractive error after cataract surgery.

IOL exchange is the preferred technique when the clinical correction of the
residual refractive error is not effective in the improvement of the visual
symptoms in patients implanted with multifocal IOLs.

Lens exchange with scleral-fixated IOL can be used for the management of late
in-the-bag IOL dislocation.

Toric IOL rotation or LASIK can treat residual excess manifest refractive
cylinder