Reuben Oza
What is negative dysphotopsia?
‘Dysphotopsia’ describes an adverse effect from cataract surgery, which can either be categorised as ‘positive’ or ‘negative’. Positive dysphotopsias refer to bright artefacts of light, often in the form of flashes, glares or haloes of light, which are most commonly located centrally or in the periphery. Conversely, negative dysphotopsias denote a temporal shadow, which is dark in character and typically arc-shaped (1). Despite not being an inflammatory or painful adverse effect of cataract surgery, dysphotopsias can be particularly bothersome to patients, and result in great anxiety and dissatisfaction post-operatively. Hence, this article aims to provide an insight into the epidemiology, pathophysiology, diagnosis and management of negative dysphotopsia to aid the clinician in counselling on this side effect pre-operatively and managing it if required.
Who does negative dysphotopsia affect?
Post-operatively, up to forty-nine percent of patients experience an element of dysphotopsia (2). With regards to negative dysphotopsia specifically, at one-month post-operatively, twelve percent experience negative dysphotopsia, with three percent of patients still affected at the one-year post-operative stage.
Why does negative dysphotopsia occur?
Whilst it is not completely understood why exactly negative dysphotopsia occurs, the predominant theory denotes a difference in illumination onto the retina between light that passes through the intra-ocular lens which are refracted posteriorly, and light that misses the intra-ocular lens and passes to the retinal periphery (1). Masket et al’s work has shown that a reason this gap in illumination may occur is due to the edge of the anterior capsulotomy overlapping with the border of the intra-ocular lens, leading to a difference in refraction between light rays which pass through the anterior capsule and intra-ocular lens (3). Another contributory factor towards the gap in illumination is the difference in characteristics between the intra-ocular lens and the physiological lens. In comparison, the physiological lens is thicker, wider in diameter and more completely fills the capsular bag (4). Hence, when an intra-ocular lens is implanted, there is additional space between the intraocular lens and the posterior iris resulting in space for the light rays at the periphery of the lens to pass undisturbed onto the periphery of the retina, which does not typically occur with the physiological lens.
Diagnosis
Diagnosis of negative dysphotopsia is largely clinical and relies on eliciting the clinical features described in the “Introduction” section. Additionally, it is particularly important to exclude other causes of visual dysfunction post-cataract surgery, including posterior capsule opacification, retinal detachment and posterior vitreous detachment (1).
Management
As with all adverse effects, the initial approach should be to prevent occurrence. Choice of intra-ocular lens can help to reduce the likelihood of dysphotopsia (2) Lenses with a lower index of refraction are less likely to lead to a gap in illumination due to causing less internal reflection (1). Similarly, round-edged intra-ocular lenses have been found to reduce the incidence of dysphotopsia but conversely are associated with an increased risk of posterior capsule opacification.
If negative dysphotopsia does occur, given that it often spontaneously self-resolves, management is largely conservative, with optimisation of refractive errors and ocular surface health. If negative dysphotopsia persists, or is particularly bothersome, surgical intervention can be taken. Options include ‘reverse optic capture’, in which the intra-ocular lens is implanted anteriorly to the anterior capsulotomy, or alternatively implanting a ‘piggy-back’ or ‘sulcus-placed’ additional intra-ocular lens, which help to minimise the gap in illumination caused by the intra-ocular lens (1).
References
- Verkade A, Houser K, Percelay PJ, Lovett R, Patel AS, DelMonte DW, McMillan J, Christenbury J. Dysphotopsia [Internet]. EyeWiki; 2025 Jun 30 [cited 2025 Jul 10]. Available from: https://eyewiki.org/Dysphotopsia
- American Academy of Ophthalmology. Managing dysphotopsias from cataract surgery [Internet]. San Francisco (CA): AAO; 2023 Jan [cited 2025 Jul 10]. Available from: https://www.aao.org/eyenet/article/managing-dysphotopsias-from-cataract-surgery
- Masket S, Fram NR, Cho A, Park I, Pham D. Surgical management of negative dysphotopsia. J Cataract Refract Surg. 2018 Jan; 44(1): 6–16. Available from: https://doi.org/10.1016/j.jcrs.2017.10.038
- Mayo Clinic. Optic effect on peripheral retinal illumination holds implications for negative dysphotopsia [Internet]. Rochester (MN): Mayo Clinic; 2022 Mar 12 [cited 2025 Jul 10]. Available from: https://www.mayoclinic.org/medical-professionals/ophthalmology/news/optic-effect-on-peripheral-retinal-illumination-holds-implications-for-negative-dysphotopsia/mac-20528776