Managing A New Patient Presenting With A Refractive Surprise Post Cataract Surgery In One Eye And A Cataract In The Other

Managing an unhappy patient as a result of your own surgery is a delicate process requiring time and thought. Addressing the needs of a new patient presenting with a refractive surprise following cataract surgery elsewhere, a cataract in the other eye and an aim of being spectacle independent makes the task considerably harder. This case report demonstrates how a detailed history, thorough optometric evaluation, accurate biometric measurements and immaculate surgery using premium IOLs, such as the Rayner Sulcoflex and Rayner EMV, can give you, and the patient, the result they want.

OCL Vision, London, UK

This 72-year-old myope who successfully wore contact lenses with monovision underwent right eye (RE) cataract surgery elsewhere with a monofocal IOL, with an aim of replicating his monovision set up; emmetropia in the RE with a plan of left eye (LE) surgery further down the line aiming for myopia. He presented in our clinic, for the first time, with no previous biometry, unhappy, with a refractive surprise of -3.38DS spherical equivalent (SE) in the RE (-2.75/-1.25 x 90). His untreated LE was -5.25DS. After discussions and thorough testing, involving a contact lens trial, it was decided that for his visual requirements he would need his RE for distance and LE for close work. Switching the monovision set up to leave his RE for near was not suitable and he would need further surgery in the RE to correct the residual prescription. Pentacam tomography of the RE showed a thin cornea with CCT of 455µm with corneal astigamatism of 1.2D at 4.7^o. Back surface elevation also meant that laser vision correction was not suitable. After a through refraction, duplicate measurements of biometry and Pentacam, he subsequently underwent successful surgery in the right eye with a Rayner Sulcoflex Aspheric IOL piggyback lens and thereafter LE cataract surgery using the Rayner EMV aiming for -1.50 for an increased near vision range.

His post op outcome measured LogMAR -0.20 UDVA and N4 (LogMAR 0.2) UNVA with a great range of 35-65cm and he was delighted with the outcome.  

This case report demonstrates the importance of teamwork in providing the best outcome for your patient. Careful scanning and interpretation of scans are necessary to determine why there had been a refractive surprise. Discussions with the patient to determine what their requirements are as well as a very careful refraction are crucial to determine how best to proceed. The use of special IOLs such as the Rayner Sulcoflex IOL helps achieve optimal outcomes due to the stable and design of the lens. Enhacned monofocal IOLs can be use in a monovision set up to provide a greater range of close vision where needed.