Addressing Dissatisfaction with Dysphotopsia

With up to 20% of patients implanted with either partial range of focus enhanced IOLs or full range of focus smooth transition IOLs reporting some level of dissatisfaction with their postoperative results, good preoperative counselling is essential, stresses Lars Morten Holm MD, PhD.

“We did a study in my clinic on the satisfaction rates of cataract patients, delivering patient-reported outcome (PRO) questionnaires,” Dr Holm said. “Surprisingly, there was no significant difference between extended depth of focus (EDOF) and monofocal IOLs.”

The literature showed blurred vision as the main complaint with full range of focus smooth transition (FULL-RoF-Smooth-Transition) IOLs as well as partial range of focus extend (PARTIAL-RoF-Extend) IOLs, with 13% of patients reporting it in both groups. Positive dysphotopsia (or, more precisely, photic phenomena) was present in 39% to 80% of FULL-RoF-Smooth-Transition IOL patients, with halos as the most commonly noted phenomenon. However, the majority were not bothered by these effects. The frequency of glare, halo, and starbursts in the PARTIAL-RoF-Extend IOL group from Dr Holm’s clinic was around 4%—not significantly different from the monofocal results.

Among dissatisfied referred patients, the dominant complaint was blurred vision, as evidenced by 75% of patients in the PARTIAL-RoF-Extend lens group versus 62% of patients in the FULL-RoF-Smooth-Transition lens group, Dr Holm said. Ametropia emerged as the main reason for these high

percentages (55–65%), followed by dry eye disease (4–26%), posterior capsular opacification (PCO, 12–16%), and large pupil (15%). Other issues included maculopathy (such as cystoid macular oedema), epithelial basement membrane dystrophy, Fuchs’ dystrophy, floaters, diabetic macular oedema, minimonovision intolerance, and epiretinal membrane, Dr Holm noted.

Evaluating the unhappy patient

When evaluating an unhappy patient at the clinic, Dr Holm suggested combining good counselling with a review of the patient’s ocular history. The investigation should include whether the patient was a good candidate from the start and if there were signs of amblyopia from previous strabismus surgery (or any other ocular surgery), a challenged retina from a retinal detachment surgery, or a challenged cornea from a laser surgery. Surgeons should note the preoperative refraction since previous myopic patients have high demands for near visual acuity. Moreover, he suggested paying attention to whether the dissatisfaction occurred immediately after implantation or later, as this may indicate the reason for dissatisfaction.

After considering these causes of dissatisfaction, surgeons should evaluate whether the patient has PCO, macular oedema, or floaters that developed in the weeks or months after implantation, or PCO or a calcified lens that developed years later.

The eye examination needs to be thorough, Dr Holm said, noting the refraction must be subjective because autorefraction can be misleading. Pupil size greater than 5.0 mm mesopic or 6.0 mm scotopic can impact night driving due to the exposure of more optical zones.

Before considering a surgical approach with these dissatisfied patients, Dr Holm recommended first prescribing spectacles or contact lenses as an ametropia treatment. Moreover, the surgeon should be able to explain the reason for dysphotopsia and negotiate a viable solution. According to Dr Holm, only 2% of patients will fail to neuroadapt. Of these, 4% will continue to be intolerant of dysphotopsia and should be counselled for IOL exchange.

Dr Holm spoke at the 2026 ESCRS Winter Meeting in Helsinki.

Lars Morten Holm MD, PhD is Clinical Associate Professor, University of Copenhagen, Denmark. lars.morten.holm.01@regionh.dk