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Cataract Surgery | Oct 2009

Managing the Dissatisfied Presbyopia IOL Patient

Learn how to be an ally to your patient.

In addressing any patient who is a candidate for a presbyopia-correcting IOL, an ounce of prevention is better than a pound of cure. We begin our screening process by letting all patients know there is not yet a perfect device for the correction of presbyopia. Patient selection is paramount in the process. The best-suited patients for presbyopia-correcting IOLs should be appropriately motivated and have reasonable expectations and a high probability of achieving their goals. We exclude patients who are highly argumentative, hostile, or inadequately capable of comprehending our explanations.


Communication is the key to managing patient expectations. A physician has a discussion with each patient, which commences with a detailed analysis of his needs, desires, and expectations. We provide the patient with statistical data on our ability to meet his needs; we disclose the rate of success in our office with each of the devices and with people whose goals are similar. We never guarantee spectacle independence, and we explain what enhanced functional vision is (ie, less dependence on spectacles, as distinct from total spectacle independence). We provide our personal results, enhancement techniques, and the rates of enhancements in our office. We convey a commitment to help each patient achieve his goals and display a willingness to go the extra mile.

Out of necessity, we must be knowledgeable and have adequate skills to provide enhancements. We anticipate—and are prepared for—a prolonged postop follow-up course. All of this requires an expanded informed consent process. We must provide information regarding all options and IOL choices, discussing the strengths, weaknesses, and compromises of each IOL. We explain the concept of mixing and matching IOLs and recommend a specific IOL, which every patient will ask for. Finally, we offer a detailed explanation of possible complications and their statistical incidence. We cannot know what patients want without adequately talking with them. We try to under-promise and over-produce.

Assuming that the technical aspects of the patient-care process have met the standard of care—preoperative counseling, preoperative work-up, and the surgical procedure itself—we are still left with managing some patients' dissatisfaction postoperatively.

Postoperative communication is different from preoperative communication. During postoperative care, there may be elements of patient hostility, which you must avoid being provoked by. Instead, always listen to whatever the patient wants to tell you. Frequently, the patient will come in with a list of questions and/or concerns. Although we have heard it all before, the patient wants to go over the entire list because he thinks it is important for the doctor to know what he is experiencing. Often after verbalizing the list the patient will say, "But I want you to know, doctor, that I am delighted." If you cut the patient off and do not let him go through the list, he may leave your office less then delighted.

Always acknowledge patient concerns. Patients know they have unlimited access to our office, and we convince them we will do whatever we can to help them achieve their goals. We demonstrate the measure of improved functional vision that they have achieved. Sometimes they are not as aware of it until we demonstrate it for them. We also always acknowledge what we have failed to achieve. We never offer explantation and exchange of the IOL, but we do it if the patient insists. We commence the process by asking the patient to wait for the eye to settle down before we do anything.

Address the remaining deficiencies. After the briefest but adequate delay, we address any remaining deficit in the outcomes. For example, we use limbal relaxing incisions for residual astigmatism, piggyback IOLs for power adjustment, or LASIK for either or both. Occasionally, if the result is not perfect but the outcome has advantages, we may recommend operating on the second eye prior to attempting to enhance the outcome in the first eye. A good example of this is a patient with excellent near vision but inadequate intermediate vision. Here, we would use some form of mixing and matching IOL technologies.

Postoperative surgical refinement involves several options or, in some cases, a combination of options, including LASIK, sulcus placement of a piggyback IOL, movement of an IOL out of the bag and into the sulcus to reduce mild hyperopia, and limbal relaxing incisions. We may address the compromises in the first eye with mini-monovision, using the same lens in the second eye or using a different lens in the second eye that compensates for the inadequacies of the first eye lens. Spectacle independence and patient satisfaction depend on minimizing compromises. They are not equivalent.

Communication is the key. Over time, many patients adjust to their new functional vision with its advantages and disadvantages and become less dissatisfied and happier, but only if they see the surgeon as their advocate.

In summary, each patient must view the surgeon, as his ally. We have adequately informed him, walked with him through the process, done everything surgically possible, demonstrated what has been gained, acknowledged what has not been gained, and provided hope and reassurance. In most cases, patients realize they have been greatly improved and aresatisfied.

I. Howard Fine, MD, is a Clinical Professor of Ophthalmology at the Casey Eye Institute, Oregon Health & Science University and is in private practice at Drs. Fine, Hoffman, & Packer LLC, Eugene, Oregon. Dr. Fine states that he is a paid consultant to Abbott Medical Optics, Inc., Bausch & Lomb, iScience, Carl Zeiss Meditec AG, and Omeros Corporation. He is a member of the CRST Europe Global Advisory Board. Dr. Fine may be reached at tel: +1 541 687 2110; e-mail: hfine@finemd.com.

Richard S. Hoffman, MD, is a Clinical Associate Professor of Ophthalmology at the Casey Eye Institute, Oregon Health & Science University, and is in private practice at Drs. Fine, Hoffman, & Packer, LLC, Eugene, Oregon. He states that he has no financial interest in the products or companies mentioned. Dr. Hoffman may be reached at tel: +1 541 687 2110; e-mail: rshoffman@finemd.com.

Mark Packer, MD, FACS, is a Clinical Associate Professor at the Casey Eye Institute, Department of Ophthalmology, Oregon Health & Science University, and is in private practice at Drs. Fine, Hoffman & Packer, LLC, Eugene, Oregon. He states that he is a consultant to Abbott Medical Optics, Inc., Bausch & Lomb, Advanced Vision Science, Carl Zeiss Meditec AG, Carl Zeiss, Inc., Celgene Corp., Ista Pharmaceuticals, Gerson Lehman Group, iTherapeutix, Vistakon, Leerink Swann & Company, Transcend Medical, Visiogen, Vision Care, WaveTec Vision Systems, and TrueVision. Dr. Packer may be reached at tel: +1 541 6872110; e-mail: mpacker@finemd.com.