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28 | EYEWORLD DAILY NEWS | MAY 5, 2019 ASCRS SYMPOSIA ASCRS ASOA ANNUAL MEETING by Rich Daly EyeWorld Contributing Writer that the patient has some residual refractive error and they might be totally happy, so are we treating ourselves or are we treating the patient?" Dr. Donaldson said. It's also important to under- stand the patient's expectations and whether they will be tolerant of waiting an appropriate amount of time. "Communication is key with these patients; we need to make sure that we take the time to es- tablish a trusting relationship that they can stick with throughout this process," Dr. Donaldson said. Effectively treating residual re- fractive error is the most import- ant way for surgeons to improve patient satisfaction. She encour- aged surgeons to use positive terms to describe postop treat- ments for residual error, including "adjustments." When surgeons are confront- ed with complaints from patients with residual error who cite the better outcomes achieved by "most of their friends," Dr. Don- aldson reminds them that only a small number of her premium IOL patients are not happy with their vision after implantation. "Nothing is 100% and there always are a few patients who need a couple extra steps, so we have the things in place to help those patients," Dr. Donaldson said. "But I wouldn't do this if most of my patients weren't happy, and that's why we're going through this process." David Chang, MD, Los Altos, California, explains preop to patients that the procedure differs from contact lenses in that he can repeatedly try different contact lens powers but he only gets one chance with an IOL to get it right. Editors' note: Drs. Donaldson and Chang have financial interests with various ophthalmic companies. surgeons may need to consider IOL exchange, the addition of a piggyback IOL, or laser vision correction. Next, surgeons should de- termine if the residual error is myopic or hyperopic. "Myopic is very easy to treat with LASIK; hyperopic LASIK, a lot of the time, leads to higher order aberrations and less satisfac- tory results," Dr. Donaldson said. In terms of determining if the error is spherical or cylindrical, error causes can vary based on the lens type. For monofocal lenses, consider whether it was toric or non-toric and whether the lens has shifted or is the wrong power. For multifocal lenses, small errors in rotation or power can be magnified, Dr. Donaldson said. "If you have a patient with a large amount of astigmatism, even one clock hour off can be dev- astating, and a small rotation can lead to perfect vision once again," Dr. Donaldson said. A final key is better under- standing the patient. "Sometimes you might notice component that is off ? Who is the patient? Key possibilities on why the residual refractive error occurred include an error in preop mea- surements, an underlying medical condition, the effective lens posi- tion, or the presence of posterior corneal astigmatism. The main sources of error in preop measurements include poor tear film and dry eye syndrome. If the topography is not optimal, Dr. Donaldson suggested addressing the tear film and reas- sessing at a later day. "If the topography or to- mography is not optimal, repeat it again and again; patients really do appreciate that extra time you spend taking the proper measure- ments," Dr. Donaldson said. Additionally, she suggested using select technicians, measuring before drops, and repeating mea- surements in unusual eyes. The response should de- pend on the residual error. In cases where it is small, patients can benefit from just treating the ocular surface. For large errors, S urgeons can benefit from following five steps in cases of unhappy postop refractive patients, said Kendall Donaldson, MD, Plantation, Florida. A 2016 study Dr. Donaldson co-authored found that residual refractive error was the leading reason (57%) for dissatisfaction post-premium IOL surgery. In comparison, dry eye disease (35%) was the second lead- ing reason for their dissatisfaction. "To meet the refractive target, we have to be within 0.5 D of the refractive target," Dr. Donaldson said. "But sometimes a little miss can be just horrible." On those rare occasions, surgeons can benefit from asking themselves five questions: Why did it happen? How large is the refractive error? Is it a myopic or hyperopic error? Is it the spheri- cal component or the cylindrical 5 pearls to postop refractive enhancement EYEWORLD DIGITAL Experience EyeWorld's print publications online • EyeWorld news magazine • CME supplements • Non-CME supplements • EyeWorld Daily News • Archives Digital.EyeWorld.org

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