Refractive surgical problem:

Article Outline

• Copyright

A healthy 22-year-old woman had implantation of phakic intraocular lenses (pIOLs) in both eyes. Before surgery, uncorrected visual acuity (UCVA) in the right eye was 1/15; best corrected visual acuity (BCVA) was 0.8 (20/25) with −6.00 −2.75 × 9 (spherical equivalent [SE] −7.375 diopters [D]). In the left eye, UCVA was 1/15 and the BCVA was 0.8 (20/25) with −7.25 −2.00 × 175 (SE −8.25 D).

The intraocular pressure (IOP) was 10 mm Hg in the right eye and 11 mm Hg in the left eye. Central pachymetry was 528 μm and 534 μm, respectively. Anterior chamber examination and fundoscopy were normal. In the right eye, the pupil was 7.43 mm under scotopic conditions, 6.93 mm under mesopic conditions, and 5.03 mm under photopic conditions. In the left eye, the pupil was 7.42 mm, 6.82 mm, and 5.13 mm, respectively. The endothelial cell count was 2659 cells/mm² in the right eye and 3105 cells/mm² in the left eye.

The patient reports having strabismus in childhood and no ocular trauma or previous ocular surgery. Refraction had been stable over the past 3 years, and the patient had been wearing soft contact lenses for 3 years.

One week before surgery, 1 neodymium:YAG iridotomy was performed in each eye. In both eyes, a toric Artisan pIOL (AMO) with an optic diameter of 5.0 mm was implanted through a superior scleral tunnel incision. The IOL power was −6.50 −3.00 × 0 (implanted at 9-degree axis) in the right eye and −8.00 −2.00 × 0 (implanted at 175- degree axis) in the left eye. Postoperative medication was dexamethasone and neomycin (Isopto-Max AT) 3 times a day for 4 weeks and artificial tears when required.

On the third postoperative day (right eye) and first postoperative day (left eye), UCVA was 0.50 (20/40) in the right eye and 0.63 (20/32) in the left eye. Subjective refraction was +1.25 −2.50 × 138 and +0.75 −1.50 × 86, respectively. The BCVA was 0.5 in the right eye and 0.8 in the left eye.

Three weeks postoperatively, UCVA was 0.4 in both eyes. Subjective refraction was −1.25 @ 110 and −1.50 @ 83, respectively, with a BCVA of 0.80 (20/25) in both eyes. The IOP was 17 mm Hg in both eyes. The patient reported that far vision and near vision were excellent; however, intermediate vision was weak. At present, 1 week later, both pupils are larger than the IOL optics and the patient reports glare. Intraocular pressure is 12 mm Hg in both eyes. Uncorrected visual acuity is 0.3 (20/63) in the right eye and 0.5 (20/40) in the left eye, and BCVA is 0.7 (20/32) and 0.8 (20/25), respectively. Subjective refraction is +1.00 −2.00 × 110 and +0.50 −1.25 × 83, respectively.

Figure 1 shows the preoperative wavefront images. Figure 2 shows the preoperative Orbscan maps and Figure 3, the Orbscan maps 3 weeks after surgery.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 1. 

  Preoperative wavefront. A: Right eye. B: Left eye.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 2. 

  Preoperative Orbscan. A: Right eye. B: Left eye.

• 
  • View Large Image
  • Download to PowerPoint

• Figure 3. 

  Orbscan 3 weeks after surgery. A: Right eye. B: Left eye.

The patient is unhappy with the outcomes and reports glare and halos as well as reduced UCVA. How would you alleviate the patient's discomfort?