Understanding the Dysphotopsias

Educational Objectives

The goals of this program are to improve the diagnosis and treatment of lacrimal overflow and dysphotopsias. After hearing and assimilating this program, the clinician will be better able to:

1. Explain the causes of positive dysphotopsia.

2. Debate current theories of the cause of negative dysphotopsia.

Summary

Dysphotopsia: subjective optical images associated with uncomplicated implantation of monofocal intraocular lenses (IOLs); positive dysphotopsia (PD) — patients see streaks, central flashes, haloes, and arcs of light; negative dysphotopsia (ND) — patients see temporal dark shadows; dysphotopsia chief cause of dissatisfaction after uncomplicated cataract surgery; ND present in 15% of cases on first postoperative day, 3% at 1 yr, and 2% at 2 yr

Diagnosis: relies on patient-reported outcomes; dysphotopsia differs from glare, Purkinje images, and Maddox rod effects related to striae in capsular bag; edge-induced dysphotopsia described after introduction of oval IOLs with square edges; reflectometry and ray tracing demonstrate effects of square edge on vision; PD caused by high index of refraction, low curvature, and square edge; manufacturers responded by modifying square edge, reducing polishing, decreasing thickness of edge, moving optical power anteriorly, and using materials with lower index of refraction, but did not alter surface reflectivity; however, changes did not reduce ND

Positive dysphotopsia: managed with brimonidine (Alphagan) or pilocarpine; if miotics ineffective, IOL must be replaced; collamer IOL (eg, Staar nanoFLEX) good choice

Negative dysphotopsia: etiology — disputed; ray tracing analysis implies that edge design, material, and depth of posterior chamber responsible, but clinical findings show problem to be related to relationship of IOL to capsular bag; symptoms initiated by temporal source of light; adding thick temporal pieces to eyeglasses relieves problem; symptoms worsen when pupil constricted and dissipate when pupil dilated; visual field tests normal; ND occurs despite perfect surgical technique; role of type of implantation — some authors believed square edge and high incidence of refraction of AcrySof IOL caused problem, but ND reported primarily when IOL placed in bag; fixation of AcrySof lens in sulcus corrected symptoms; ND occurs with other types of IOLs; expanded depth of posterior chamber after implantation of IOL investigated as cause, but distance from iris to optic similar in symptomatic patients and controls; not corrected by placing different IOL in bag but by fixation in sulcus; ND reported after temporal and superior incisions but not after other surgeries involving corneal incisions (ie, incision not responsible)

Summary: etiology of ND not related to type of IOL, depth of posterior chamber, or corneal incision; usually occurs in early postoperative period and then resolves; ND not reported with ciliary sulcus lens, sutured scleral fixation, glued IOL, or IOL in anterior chamber; any IOL in bag may cause ND; to prevent or treat, edge of optic must overlie anterior capsulotomy; piggyback lenses used with some benefit in Europe

Management: edge of optic should be elevated anteriorly or sulcus IOL implanted; lens epithelial cells should be removed; rigid capsular tension ring optional; capsulotomy must be properly sized and located; femtosecond laser (FSL) spatula helps to lift edge of anterior capsulotomy

Complications: eg, posterior capsule opacification, chafing of iris; optic should be anterior to capsulotomy but bulk of lens in bag; lens designed for this purpose being investigated in Europe; perfect capsulotomy made with FSL on visual axis should eliminate higher-order aberrations

Readings

Allen RC: Hereditary disorders affecting the lacrimal system. Curr Opin Ophthalmol 2014 Sep;25(5):424-31; Burke TR and Benjamin L: Sulcus-fixated intraocular lens implantation for the management of negative dysphotopsia. J Cataract Refract Surg 2014 Sep;40(9):1469-72; Cavazza S et al: Congenital dacryocystocele: diagnosis and treatment. Acta Otorhinolaryngologica Italica 2008;28(6):298-301; Davison JA: Positive and negative dysphotopsia in patients with acrylic intraocular lenses. J Cataract Refract Surg 2000 Sep;26(9):1346-55; Detorakis ET et al: Lacrimal outflow mechanisms and the role of scintigraphy: current trends. World J Nucl Med 2014 Jan;13(1):16-21; Erie JC et al: Analysis of postoperative glare and intraocular lens design. J Cataract Refract Surg 2001 Apr;27(4):614-21; Folden DV: Neodymium:YAG laser anterior capsulectomy: surgical option in the management of negative dysphotopsia. J Cataract Refract Surg 2013 Jul;39(7):1110-5; Holladay JT et al: Negative dysphotopsia: the enigmatic penumbra. J Cataract Refract Surg 2012 Jul;38(7):1251-65; Hong X et al: Ray-tracing optical modeling of negative dysphotopsia. J Biomed Opt 2011 Dec;16(12):125001; Maliborski A and Różycki R: Diagnostic imaging of the nasolacrimal drainage system. Part I. Radiological anatomy of lacrimal pathways. Physiology of tear secretion and tear outflow. Med Sci Monit 2014 Apr 17;20:628-38; Masket S and Fram NR: Pseudophakic negative dysphotopsia: Surgical management and new theory of etiology. J Cataract Refract Surg 2011 Jul;37(7):1199-207; Masket S et al: Undesired light images associated with ovoid intraocular lenses. J Cataract Refract Surg 1993 Nov;19(6):690-4; Osher RH: Differentiating transient and permanent negative dysphotopsia. J Cataract Refract Surg 2010 Sep;36(9):1619; author reply 161-9; Osher RH: Negative dysphotopsia: long-term study and possible explanation for transient symptoms. J Cataract Refract Surg 2008 Oct;34(10):1699-707; Palaniswamy SS and Subramanyam P: Dacryoscintigraphy: an effective tool in the evaluation of postoperative epiphora. Nucl Med Commun 2012 Mar;33(3):262-7; Tester R et al: Dysphotopsia in phakic and pseudophakic patients: incidence and relation to intraocular lens type (2). J Cataract Refract Surg 2000 Jun;26(6):810-6; Trattler WB et al: Negative dysphotopsia after intraocular lens implantation irrespective of design and material. J Cataract Refract Surg 2005 Apr;31(4):841-5; Vámosi P et al: Intraocular lens exchange in patients with negative dysphotopsia symptoms. J Cataract Refract Surg 2010 Mar;36(3):418-24; Welch NR et al: Satisfaction and dysphotopsia in the pseudophakic patient. Can J Ophthalmol 2010 Apr;45(2):140-3.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Masket holds a trademark licensing agreement (patent holder) with MORCHER GmbH. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Masket spoke at Controversies in Ophthalmology, presented by the Research Study Club of Los Angeles, and held on February 7, 2015, in Los Angeles, CA. For information about courses sponsored by the Research Study club, please visit www.researchstudyclub.com. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OP531302

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.