January consultation # 5

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This patient's main complaint is related to incomplete coverage of the pupil by the pIOL optic. The toric Artisan pIOL used in this case has a 5.0 mm optic, which is too small to cover this patient's pupil entirely, even under photopic conditions. Under these circumstances, the occurrence of postoperative glare could have been anticipated. The peripheral iridectomy can also be a rare cause of postoperative glare, but as we have no information about the location and the width of the iridectomies, I suppose this is not the case. In addition, the patient reports poor UCVA, probably because she was a contact lens wearer and was therefore expecting almost perfect vision after refractive surgery. The decrease in UCVA is probably due to the small change in the postoperative astigmatism involved with any incision larger than 3.0 mm, leading to overcorrection of the cylinder, as can be observed in the Orbscan maps.

Actually, this was a difficult case in light of the relatively high myopia, astigmatism, thin corneas, large pupils, and contact lens wear. In such cases, the possible drawbacks of any refractive surgery should be thoroughly discussed. When pIOL implantation is selected, the relatively long time required for the corneal incisions to stabilize, the possible correction of the residual refractive error by excimer laser, and the possibility of pIOL removal in the case of anatomical or optical complications should be mentioned. In the case of excimer laser surgery, the possibility of postoperative halos at night should be mentioned as well. After observing the results of surgery and the current status of this patient, I believe that a posterior chamber pIOL or a corneal procedure would probably have given better results, although a larger anterior chamber pIOL would likely have produced some patient dissatisfaction as well.

Fortunately, there are solutions to this patient's problems. The best would to exchange the toric Artisan pIOL for a posterior chamber Staar Collamer spherical pIOL, followed by excimer laser corneal surgery if required. The IOL exchange should resolve the glare and halos, and LASIK should improve UCVA, also correcting the residual astigmatism. If the patient is too dissatisfied to accept a second pIOL, removal of the Artisan lens could be followed by photorefractive keratectomy, laser-assisted subepithelial keratectomy, epithelial laser in situ keratomileusis, or thin-flap LASIK using the Carriazo pendular microkeratome or a femtosecond laser. Should the patient refuse IOL removal, the only option is pharmacological pupil constriction by pilocarpine 0.1% or brimonidine eyedrops. However, pupil constriction will be accepted only in the short term and likely will only postpone surgery.