Dysphotopsia After Cataract Surgery

Dysphotopsia

Presenter:

Dr. 

Majid Moshirfar

Moderator

s

:

Jackson L. Goldberg and Tanner W. Brown

Imagine

T

his



You've 

just performed successful, 

uncomplicated cataract

surgery



Your patient 

is 20/20 

and the surgery looks

beautiful



Y

ou're ready 

to 

be

congratulated



Instead, 

your patient 

says, 

"I hate 

it! 

These 

unwanted images are 

driving 

me

crazy! You've 

got to 

do 

something about

this”



Of 

course, this isn't 

what 

you 

want 

to

hear.



But 

the reality is that dysphotopsia 

has 

become the number one problem

following uncomplicated, 

successful 

cataract

surgery.



And it doesn't 

go away easily once a patient becomes 

focused 

on

it.



Unfortunately, 

many 

of 

these patients 

are 

incredibly unhappy



Most 

of whom

are 

told 

that 

they're crazy



“Your surgery 

is 

perfect!"



"There's 

nothing 

wrong here!"



This 

has entirely 

the wrong 

effect, 

making the 

patient 

angrier 

and even 

more

focused on 

the unwanted image

The Nature of 

the

Problem



The number of patients 

who actually 

require 

an 

intraocular 

lens exchange 

is only

about 1 

in 

a

1000



However, the 

number 

of patients 

complaining 

about 

dysphotopsia is closer 

to 1 

in

10

So what's 

behind 

the current wave of

dysphotopsia 

complaints

?



The first 

element 

is 

what the patient 

is 

actually

 seeing

.



The 

second element 

is 

how 

the 

patient 

reacts to the 

symptom



The patient's reaction can be the most significant 

factor 

in resolving 

(or 

not

resolving) the

problem

What

the Patient

Sees



Temporal darkness



Arc



Flare



Central flash



In 

the literature, terms 

such

as 

photopsias,

entoptic

phenomena

photic

phenomena

have 

been 

used 

to describe 

these

images.



In June 

2000, the term “

dysphotopsia” 

was 

first

used

Dysphotopsia

Positive and Negative Dysphotopsia



Positive

dysphotopsia



is 

usually 

related to bright artifacts 

of light 

on the

retina



Negative 

dysphotopsia



is manifested by 

a 

dark crescent

or 

curved

shadow



The 

exact etiology of 

negative dysphotopsia remains 

an

enigma



The question 

of why 

this dark 

shadow of light 

occurs temporally



Because the nasal 

retina 

may extend 

further anteriorly 

than the temporal 

retina 

as

well 

as 

because light coming 

in 

nasally 

may 

be somewhat tempered by the 

nose,

eyebrow 

and

cheek

Continued

…



However, light 

coming from the temporal 

side of 

the 

eye that 

projects to the

nasal-most retina may be  deflected by the 

edge of 

the 

IOL or even 

reflected

internally by 

the 

relatively 

square edge of 

the 

IOL away 

from the nasal

retina



This results in 

a crescent-shaped shadow 

noted in the temporal field of

vision

Temporal Darkness



Temporal darkness, 

or 

negative dysphotopsia, is

the

most 

prevalent symptom 

today



30 to 

40

%*



In this 

case, 

the patient detects a 

black 

shadow 

temporally, 

in the 

periphery 

of

vision



*Vámosi P, 

Csákány 

B, Németh J. 

Intraocular 

lens 

exchange in  patients 

with 

negative 

dysphotopsia 

symptoms. 

J Cataract Refract

Surg

.

2010;36(3):418-24.

Arc



P

atient 

perceiving the edge of 

the 

IOL, which usually 

only happens at

night



It's a 

common complaint 

and 

rarely 

a serious problem



It usually resolves over 

time—especially if the capsule 

overlaps 

the 

IOL

edge

Flare



This 

is 

also a 

scotopic symptom produced by

coma



Correcting minimal cylinder 

with 

night driving 

glasses will 

often 

get 

rid 

of

it



Making 

the pupil a little smaller at 

night 

will also help

Central

F

lash



T

his appears 

to be 

caused 

by 

a

peripheral light source

reflecting off the internal edge

of 

the

IOL



Recent advances 

in 

edge 

design

have 

minimized this 

symptom

Haloes



These may be caused by 

a 

multifocal

IOL.



Produces haloes around lights from each

ring transition

zone.



Most patients 

will 

adapt to this, 

and a

smaller 

scotopic pupil can 

help 

in the

meantime.



Night 

haloes are the 

number one reason these 

IOLs are

 explanted



If 

patients 

see haloes with a 

monofocal 

IOL, 

it

usually 

indicates the 

presence of

spherical

aberration



New aspheric-optic 

IOLs will

help

How

the Patient

Reacts



Difficult to 

eliminate all 

unwanted images from patient's

vision.



The brain is 

adapt at 

eliminating 

unwanted visual 

input 

by 

phenomenon 

of

central

adaptation.



the most 

obvious 

example 

is 

the hole 

in our 

visual field where the optic 

nerve 

enters

the

eye.

Physiology

…



In 

addition, 

we

get

:



front- 

and 

backscatter off 

our 

natural

lens



pupils are

irregular



blood 

vessels 

in 

our

retin

a 

that 

we 

can't 

see

through



T

here are a lot of 

unwanted images in 

our 

field 

of  

vision, 

but our

brain 

adapts and eliminates 

them

all

Managing

Dysphotopsia



I

t

 i

s inevitable 

that some patients will experience 

unwanted

images



In these cases, 

doing 

the 

right things before 

and after surgery 

can 

avoid

the greater

problem

Create Accurate Expectations Before

Surgery



Explain to patient about dysphotopsia preoperatively



Then, the patient won't 

be surprised if 

some 

new, unwanted 

visual effect

accompanies the new

lens

Minimize the Problem Surgically



Use the right lens



Certain IOL characterstics appear to correlate with reduced dysphotopsia



Newer lenses have helped by 

increasing 

the front 

curvature 

of 

the 

lens, which

minimizes front 

and 

back 

light

scattering



Optic size 

is important, because 

a smaller lens 

may create more 

edge

problems



D0n't implant 

a lens any smaller than 6

mm



All 

the 

IOLs studied variably increased internal and external surface reflections

when 

compared  

to the human crystalline

lens.

Square Edge Design



While 

the 

square-edge optic

is clearly 

favored for 

reducing the

risk 

of

PCO, 

the trade-off for that benefit is 

an 

increased rate 

of

pseudophakic  

dysphotopsia

Pseudophakic Dysphotopsia



Square-edged 

optic is one responsible 

factor 

causing dysphotopsia



The 

other factors 

responsible

are:



the index 

of 

refraction 

of 

the 

IOL

material



corneal

curvature



pupil

size



Truncated posterior 

edge offers barrier effect 

to  

lens

epithelial

cells



Sloped edge-minimises 

internally reflected rays  that form

arc like

images



Rounded 

anterior 

edge- 

eliminates mirror

effect

C

o

ntinued…

.

.



Round

edge of 

the optic causes 

greater 

dispersion 

of 

the internally

reflected rays 

of 

light, reducing 

edge glare 

by 90

%



Increasing 

the front curvature 

of 

the 

n

ewer 

lenses has helped 

minimize

front 

and 

back light 

scattering, 

reducing

glare

Double Square Edge



When light hits 

the double-square 

edge

lens



at 

23 degrees, 

little edge

glare



at 35 

degrees, one begins to 

see

arcs



at 55 

degrees, transmitted 

as well as 

reflected 

glare 

becomes significantly more

evident

Continued….



silicone 

lens with a 

rounded edge 

and lower refractive index

seems 

to be 

most 

forgiving, producing 

the fewest 

complaints

about 

unwanted 

images

.

Place the 

lens

carefully



A 

well-centered, in-the-bag 

lens 

prevents unnecessary  optical

problems

Overlap the capsulorhexis 

rim 

over the edge of

the lens



The 

edge of 

the capsulorhexis 

will 

tend to opacify 

over

time



T

he 

opaque overlap will 

eliminate many symptoms associated 

with

the 

edge of 

the

IOL



The brain 

seems 

to ignore 

the 

edge of 

the capsule, reacting 

as 

it

does to the 

edge of 

the

pupil

Another Major Benefit



This 

strategy has 

another major

benefit



If we overlap 

the capsule, 

we will 

significantly decrease 

posterior 

capsule

opacification.



Two 

recent 

studies

, 

show that overlap 

of 

the capsule 

is more 

effective 

at preventing

"after cataract" than 

switching 

to 

an IOL 

with 

a 

truncated

edge

Continued

…



Making 

a smaller 

capsulorhexis 

has some potential 

downsides



It 

can be more difficult to 

access the 

lens, 

particularly 

if 

we 

use

the

Phaco

technique



Also, 

we 

don't 

want 

to 

risk 

capsular contracture by making the 

opening 

too

small

Continued

…



To minimize dysphotopsia 

and PCO, 

the opening 

should 

be roughly

1 mm smaller 

than the 

size of

the optic, to 

ensure 

360-degree

overlap



And use at least a 

6-mm

optic

After 

surgery, 

don't take the 

wrong attitude

if 

a 

patient

complains



The 

worst 

thing you can do if 

a 

patient complains is to

say,

"

Your

result is perfect. Nobody 

else 

is

complaining.

What's 

your

problem?"



This virtually 

guarantees 

that the 

patient will 

"turn up the gain," 

and

fail to adapt to the unwanted

images

Resolving a 

Dysphotopsia

Crisis



Talk to 

the 

patient (and say the 

right

thing).



First 

of all, let 

the 

patient 

know that 

he/she's

not  crazy. That alone 

will 

improve

matters.



Try 

night 

time pupil

constriction

Don't 

Open 

the

Capsule



Whatever 

you do, don't 

open the

capsule



Some 

ophthalmologists, thinks maybe patient 

got after cataract.



So let's go ahead and 

do 

a 

YAG capsulotomy 

and see

if that 

will 

make 

it

better



If 

the 

problem 

truly 

is dysphotopsia, 

a 

capsulotomy 

won't have 

any 

positive

effect at

all



When we 

try to take the 

lens out after a

YAG capsulotomy, 

vitreous

comes

forward.



We 

often can't put the 

lens 

back 

in 

the 

capsule because the capsulotomy

tears

further.



The risk 

of endophthalmitis and 

retinal 

detachment 

increase

dramatically.

L

ens 

E

xchange

?



Only resort to lens exchange if it really makes sense



First 

of all, 

make 

sure 

the patient 

has had enough 

time to

adapt



If even after six months problems 

continued 

then a  lens exchange 

can

be consider 

—only 

if 

it 

improve 

on  

the 

existing lens

situation.

Otherwise, switching lenses will 

be 

a waste of

time

Factors 

D

eciding 

L

ens

E

xchange



The size of the existing

capsulorhexis



If 

the optic is 

small 

then 

larger optic will 

create more 

overlap of 

the 

edge,

this can 

solve

problem



Edge

design



If 

the current 

IOL 

doesn't 

have an up-to-date edge 

design, then

switching 

to 

an 

updated 

lens would

be 

helpful



Refractive

index



If 

the current 

lens has a high 

refractive index, 

switching 

to 

a 

rounded-edge silicone 

lens

may be  curative, particularly if there 

is 

negative

dysphotopsia.



Condition of 

the

capsule



If 

another 

surgeon has 

performed 

a YAG 

capsulotomy, 

a 

lens 

exchange will 

involve more

risk.

If 

A

ll 

E

lse

F

ails



For 

some 

patients,

nothing

will

relieve

the

symptoms,

and

IOL exchange

may not

make 

sense 

if the patient

already

has

the

most beneficial type 

and size of

IOL



In that 

case, 

talk 

to 

the patient again and 

do best to 

help him 

or 

her 

to

relax



A

nd advi

s

e

 the patient

to 

stop 

thinking 

about 

it 

so 

much, 

so

the brain 

has a 

chance 

to

adapt

Pseudophakic 

Dysphotopsia with Various

Intraocular

Lens



One study was 

conducted 

on Pseudophakic 

Dysphotopsia with Various

Intraocular

Lens at Laxmi Eye Institute



Highlights of

study



The 

incidence

of

dysphotopsia found 

to be

51.12%



The 

incidence of negative dysphotopsia has 

been found to be

22.47%



The eyes 

implanted 

with 

Tecnis ZCB00 

IOL showed less 

negative temporal

shadow/darkness



Hydrophilic 

Acrylic 

IOLs showed greater 

dysphotopsia 

score 

in comparison to those

with  

Silicone

IOLs

Highlights Continued

…



Hydrophilic 

versus Hydrophobic 

Acrylic, the 

latter was 

found to be significantly better 

with a

lower 

dysphotopsia.



Hydrophobic Acrylic 

IOLs when 

compared to Hydrophilic Acrylic 

IOLs and 

Silicone 

IOLs

showed 

decrease in 

night-time

glare/halo/circles



An 

increase 

in 

the optic-haptic 

angle 

caused 

an 

increase in 

night-time 

glare/halos/circles

around 

lights.

Conclusion



Tecnis ZCB00 

emerged as least 

troublesome

lens



W

hile 

Auroflex 

FH5575 which was 

reported to 

have 

the 

highest

Dysphotopsia



Hence, 

we may conclude that 

different 

brands 

of intra-ocular lenses display

varying 

degrees 

of  

dysphotopic

symptoms

Recent

U

pdates



N

ew 

hypothesis, 

resolution 

of 

negative dysphotopsia  

symptoms

depended on intraocular 

lens (IOL)  

coverage of the anterior capsule

edge 

rather than 

on  

collapse 

of 

the 

posterior 

chamber

alone.



Negative 

dysphotopsia 

was not attributed to a  

particular 

IOL

material 

or edge

design



Pseudophakic 

negative dysphotopsia: Surgical management  

and new 

theory 

of

etiology

Journal of Cataract 

& 

Refractive 

Surgery,

06/24/2011

New Concept



Two rays, coming in 

from  

the temporal 

side at 

90°, 

are 

bent by the cornea by

about

45°



As 

they 

come 

through, 

one ray, if there is 

a 

space between the iris 

and 

the anterior

surface of 

the 

lens, 

can miss 

the front part of 

the

lens



According to Dr. 

Holladay

, 

Hawaiian Eye

meeting

New Concept



While the other ray hits  

the 

lens and is 

bent by

the  

lens's

refractive

power



In the 

cone 

between those 

two rays, no 

light 

can 

enter, 

and

this causes

what 

is 

perceived 

by the 

patient as a 

crescent-

shaped shadow*



*According to Dr. 

Holladay

, 

Hawaiian Eye

meeting



In 

the first day 

after

IOL 

implantation

, approximately 

15% 

of 

patients experience

negative dysphotopsia. By 

3 

years, the phenomenon is reduced to only

5%



To treat negative dysphotopsia, 

we have 

to eliminate the rays 

that pass 

anterior 

to

the

IOL



And 

to do 

so we have 

to 

reduce the space between the 

iris 

and 

the 

anterior surface

of 

the

IOL*



*According to Dr. 

Holladay

, 

Hawaiian Eye

meeting



This reduction may 

occur 

spontaneously in some cases 

with 

the natural forward

movement of 

the 

IOL  after 

capsular bag

contraction



The opacification 

of 

the 

equatorial 

capsule, 

occurring 

naturally 

several weeks or

months 

after 

implantation,  is 

also likely 

to reduce the 

shadow

effect



We 

can 

otherwise 

flip the optic, 

though 

this might induce

myopia



Can implant 

a 

piggyback 

IOL 

in 

the 

sulcus. 

Frosted-

edge IOLs are another

solution



Two 

surgical strategies have emerged 

as 

beneficial  treatment 

of persistent visual

symptoms of 

ND:



reverse 

optic capture

(ROC)



secondary “piggyback”

IOL

.



Failed 

surgical strategies 

include bag/bag 

IOL  

exchange wherein 

the original

implant is removed  

and 

another 

of 

different material, 

shape or edge  

design is

replaced within the capsular

bag.*



* 

This is 

in 

keeping with the work 

of Vámosi

et

al

Reverse Optic Capture



ROC 

may be employed in 

a secondary surgery 

for  

symptomatic 

patients, 

or as a

primary

prophylactic strategy



In 

cases 

of 

the 

latter, 

the 

method has 

been applied to the 

second eye of 

patients

who were 

significantly  

symptomatic 

following routine uncomplicated 

surgery 

in

their 

first

eye



It should 

be noted, 

however, 

that 

ND 

symptoms

are 

not necessarily

bilateral



Secondary ROC, performed 

for symptomatic patients, may be applied 

if 

the

anterior capsulotomy is not too 

small or 

too thick 

or 

rigid from 

postoperative

fibrosis



The first 

step 

involves freeing the anterior capsule from the underlying optic 

by

gentle blunt dissection 

and

viscodissection



Gentle 

blunt dissection 

and 

viscodissection 

of 

the anterior capsule 

from 

the

underlying

optic



Next, the 

nasal 

anterior capsule edge 

is 

retracted with 

one 

Sinskey 

hook 

(or similar

device) 

while 

the optic 

edge 

is 

elevated and 

the capsule 

edge allowed 

to 

slip 

under

the

optic



This 

maneuver 

is repeated 

180 

degrees 

away 

temporally, 

leaving 

the 

haptics

undisturbed in 

the 

bag  inferiorly 

and

 superiorly



A 

Sinskey hook 

and 

blunt

spatula 

are 

used 

to 

elevate

the 

nasal 

optic edge over

the

capsule



The haptics 

be oriented horizontally, it would be best to rotate them 90 degrees if

possible



The optic is then confirmed to be 

elevated over 

the anterior capsule 

edge 

and

the 

nasal 

and 

temporal 

edges of 

the implant 

are 

anterior 

to 

the anterior capsule,

whereas 

the 

haptics 

remain 

within the 

capsular

bag



Optic capture

has

 been

completed



The nasal 

and temporal

edges

of 

the 

implant 

are

anterior to the  anterior

capsule  

(see arrows),

whereas the haptics remain

fully 

within 

the  

capsular

bag



Once 

the nasal 

edge 

has 

been  

captured

(arrow), the 

opposite,  

temporal edge of

the optic is  elevated over the anterior

capsule  

edge

Secondary 

“Piggyback”

IOL



Secondary “piggyback” 

IOL 

is 

the other 

surgical method  that 

has proven successful

for patients with

symptomatic 

ND, 

as first reported 

by

Ernest



In this 

method, 

a 

second 

IOL 

is implanted in 

the 

ciliary 

sulcus 

above the 

primary

IOL/capsule bag

complex



It appears 

that covering the 

primary 

optic/capsule junction reduces ND

symptoms



Although the 

original 

concept was that a 

“piggyback” 

lens 

was 

effective because it

collapsed the posterior 

chamber 

by 

reducing 

the 

distance between 

the 

posterior 

iris

and 

the 

anterior surface  of the

IOL



However, studies *have determined that 

the depth 

of 

the 

posterior chamber 

is

unrelated to 

ND 

symptoms



*Vámosi et al.,march 

2011



Symptomatic patients may 

be 

good candidates for  a “piggyback” IOL if 

they 

are

also

ammetropic.



In 

order 

to qualify for a “piggyback,” 

the 

first IOL surgery should be uncomplicated

with a well-  centered IOL within the capsule

bag.



There should be no evidence of zonulopathy and 

the iris 

must be 

free 

of defects or

damage from earlier

surgery.



Although no parameters have been 

clearly 

established, it is 

better 

to perform a

UBM 

to 

ascertain adequate space (approximately 1 

mm) 

between 

the 

posterior 

iris

and 

the existing 

IOL/bag

complex

There are 

two 

kinds 

of 

light- 

the glow that illuminates

and 

the glare that

obscures.

James

Thurber

Thank you

Presenter:

Dr. 

Majid Moshirfar

Moderator

s

:

Jackson Goldberg and Tanner Brown