Patients voice concerns about cataract surgery/IOL implantation on Internet eye care forums
“Premium” IOLs have a disproportionately high number of patient complaints.
By John C. Hagan III, MD, Kansas City, Mo and Michael J. Kutryb, MD, Titusville, Fla and Michelle Stephenson.
The Internet is increasingly being used by patients to gather health information and to discuss surgical complications and outcomes. Studies suggest that Internet health forums provide a number of benefits.1-7 For example, they provide education and emotional support, and they may reduce medical costs. They may also provide unique and important medical research data different from the usual office/hospital/ASC setting.
One of the largest health care websites on the Internet is MedHelp (www.medhelp.org
), which was founded in 1994. Its forums are viewed more than 5.5 million times each month. The site includes two eye care forums (“Ask a Doctor” and “Eye Care Medical Support Community”) that are controlled by the American Academy of Ophthalmology. The eye care forums receive approximately 260,000 viewings each month. We are two of the four ophthalmologists who answer patient questions.
Multifocal IOL Study Results
To summarize internet patient concerns about cataract surgery/IOL implantation, we conducted a retrospective study8 of all postings between November 1, 2007 and May 1, 2008 on the two MedHelp eye care forums dealing with cataract surgery and IOL implantation, recovery, and satisfaction with results. We identified 750 postings and reviewed the entire discussion threads. Of these, 341 could be analyzed for causes of dissatisfaction. The multifocal IOLs were almost all ReZoom, ReStor, and Crystalens presbyopia-correcting IOLs. We summarized unwanted visual aberrations (dysphotopsia), night vision problems, blurred vision, unexpected dependence on glasses, pain, retina and other problems and patients happy with their surgical result.
All 341 discussion threads began with a question about or statement of a problem, complaint, or dissatisfaction. Two patients reported being completely blind: one due to infection and one due to bleeding. Major postoperative complications included retinal detachment, swelling of the retina, epiretinal macular membranes/macular pucker, posterior capsular opacification, displaced IOLs, IOL power/residual refractive error problems, IOL exchanges or repositioning, YAG capsulotomy, retained cortex, vitrectomy and/or scleral buckle, optic neuropathy, glaucoma, and uveitis. Minor problems included foreign body sensation, watering, persistent redness, irritation, dryness, and the need for frequent lubricants. Patients also expressed dissatisfaction about the extra expense of multifocal IOLs and the failure to achieve expected outcomes.
We were startled at the number of complaints being posted from ReZoom, ReStor, and Crystalens presbyopia-correcting IOL patients, particularly with regard to dysphotopsia and blurred vision. Although these three “premium” lenses are used in approximately 10% of patients, the volume of complaints was amazingly 6.87 times more common in presbyopia correcting IOLs (206 complaints) than all monofocal IOLs combined (30 complaints). Stated another way, each multifocal IOL was about 60 times more likely to cause an unhappy eye internet posting than a monofocal IOL. This was a wake-up call to us that many dissatisfied multifocal and accommodating IOL patients are using this Internet health site to search for information and support.
Follow-up Internet Survey Results
Recently, we conducted a second MedHelp.org Internet survey which we now report. This survey retrospectively looked specifically at comments from ReZoom, ReStor, and Crystalens presbyopia-correcting IOL patients during the entire year of 2008. (Table 1). Using key words, we found a total of 210 presbyopia-correction IOL patients posted comments. Seventy percent reported being unhappy, usually due to glare and halos (68%), difficulty seeing at night (59%), and dependence on glasses (58%).
Sixty of the 210 patients were implanted with the ReZoom lens. Of these, 3 (5%) were happy, while 54 (90%) were unhappy. Seventy-seven patients were implanted with the ReStor lens. Of these, 18 (23%) were happy, while 55 (71%) were unhappy. Seventy-three patients were implanted with the Crystalens. Of these, 21 (29%) were happy, and 38 (52%) were unhappy. The percentages do not add to 100 because some patients did not express their satisfaction or dissatisfaction or comment about a specific problem.
Of the 3 lenses, the ReZoom lens had the highest percentage of unhappy patients. Zelichowska et al recently stated9, “Few reports describe visual performance after implantation of the ReZoom IOLS, and, to our knowledge, none discusses the optical performance of the IOL in situ.” Our studies should be considered by all surgeons, especially those who are using or considering the ReZoom Lens. Our studies suggest that ReZoom’s older technology is more prone to produce clinical problems and unhappy patients. The Crystalens had the lowest number of unhappy patients.
2009 MedHelp postings indicate the Crystalens HD and Acrysof IQ ReStor IOL are producing happier patients and fewer complaints. The ReZoom remains problematic.
It is important to note, however, that our study protocol has some limitations. It is retrospective and has no control group. Additionally, most people with favorable outcomes probably do not visit health care forums to share their good results as often as people with unfavorable outcomes. Older patients may not have the same access to and ability to use the internet as younger patients.
Are These Lenses “Premium”?
Many of the patients expressed extreme dissatisfaction with their surgical results; particularly because they were told they were receiving a "premium lens", paid thousands of dollars out of pocket and had higher unrealized expectations. They not infrequently reported pressure to upgrade to “premium” IOLs. One patient described her surgeon telling her, “You don’t want a government issue implant in your eye do you?” Given the much higher complication rate, greater cost and dissatisfaction among presbyopia correction IOL patients perhaps “premium” is a misnomer.
Internet health forums have been used infrequently in Medicine and not at all in Ophthalmology to study patient reported complications and satisfaction/dissatisfaction with surgical procedures. Our two studies are first literature reports and offer unique and valuable insights. We believe that patients for presbyopia correcting IOLs need to be more carefully selected and educated on possible operative and post operative complications. Realistic expectations must be instilled. All patients need to know about dysphotopsia and night visual problems. The Crystalens HD and IQ ReStor IOLs offer the highest degree of patient satisfaction. We discourage use of the ReZoom IOL.
Given that many patients complained their surgeon didn’t listen to or ignored their complaints it’s likely that there is unrecognized and/or not reported patient dissatisfaction. This may account for the flat market share and stagnant number of surgeons using presbyopia correcting IOLs. Surgeons may also want to create a protocol to proactively seek out and handle unhappy patients. Perhaps all these patients should complete a survey looking for unrecognized dissatisfaction 3, 6, 9 and 12 months post operatively. The lens manufacturers, as well, might want to consider having a proactive program for assisting unhappy patients. In the survey, several Crystalens patients commented on how Bausch and Lomb representatives had participated in trying to solve postoperative problems, and we believe this made a very positive impression on the patients.
Dr. Hagan is in private practice in Kansas City, Mo., and Dr. Kutryb is in private practice in Titusville, Fla.
Financial Disclosures: None for Dr. Hagan or Dr. Kutryb
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TABLE 1 HAGAN/KUTRYB ARTICLE SENT BY E MAIL TO C GLENN AND M STEPHENSON 2/24/09