Up Front | Oct 2016

The Paradox of Choice


There is no doubt that having choices is good. Yet I have also found the converse to be true: that too many options can be a bad thing. Not long ago, a colleague was looking to buy a new car. The timing was right, the budget was there, and his wife was prompting him to buy the new car. After test-driving every car that interested him, however, he ended up confused and decided to stay with his current vehicle. Likewise, there was a news story in which a supermarket that sold 25 different relishes saw turnover in this section increase dramatically when it reduced the choice down to just three. Why is this, and what is happening here?

It appears that, when bombarded with choices, we become fearful of making the wrong decision. What if we did not choose the best option? What if we left one out that was the better choice for us? Are we missing out if we have not chosen wisely? You can see where this is going—but how does this apply to refractive surgery and refractive cataract surgery?

We now have so many good options for correcting vision that, sometimes, even we professionals are unsure of the best technology to use. Attending conferences, reading publications such as CRST Europe, talking to colleagues—these all help to educate us.

If you think our range of choices is daunting, think about the patient for a moment, especially the presbyopic patient whose choices aside from spectacles and contact lenses range from laser vision correction (LVC) and corneal inlays to refractive lens exchange and phakic IOLs. Within LVC there is PRK, transepithelial PRK, LASEK, epi-LASIK, LASIK, and SMILE. This is without even mentioning presbyopia-correcting LVC options. In the context of corneal inlays for presbyopia, there is the Kamra (AcuFocus), the Raindrop (ReVision Optics), and the Flexivue Microlens (Presbia), as well as the promise of new technologies such as the TransForm (Allotex). What is the patient to choose?

The IOL options are even greater. In addition to monofocal IOLs with various forms of monovision, patients have multifocal, trifocal, extended depth of focus/extended range of vision, small-aperture, and accommodating IOLs to consider.

When buying a new car, consumers are confronted with selecting the brand and model that has the features that appeal most to them. That is it. Each consumer simply matches the features of the car to what he or she is seeking in order to find the best fit. There is no dealing with different brands talking the other brands down. Automobile manufacturers say good things about their competitors. So do orthodontists and aesthetic and plastic surgeons for the most part. In our world, however, this is not always the case. Each of us has heard colleagues and companies make claims that one technology or solution is better than another and that their offerings are best. Sometimes a competing technology is shot down, and colleagues have also been known to refer disrespectfully to other colleagues, facilities, or institutions.

Can you imagine how this confuses our patients? The noise in the marketplace is deafening, and the patient’s ability to make decisions diminishes as the noise increases.

This is one of the reasons that LVC is not growing in most markets and why the advanced-technology IOL market is performing below its potential. If you can, take the time to watch Barry Schwartz’s TED talk on the paradox of choice or read his book on the same topic.1,2 I think you will find it hard to disagree that too much choice hampers economic activity.

Furthermore, if you think that refractive errors are a problem in the first world only, you are mistaken. According to a recent article,3 untreated refractive errors are the leading cause of visual impairment and the second leading cause of blindness after cataract. The work that we do as refractive surgeons and as refractive cataract surgeons cannot be underestimated, and we should all be part of a collaborative effort to help reduce this error for as many people as possible.

The most promising news I have encountered to help address these issues is the emergence of the Refractive Surgery Alliance (RSA). If you would like to grow your refractive practice by growing the entire refractive surgery market, bringing the benefits of refractive surgery to more people, then this society is for you.

There has never been a better time to be an ophthalmologist, and there has never been a better time for patients seeking to improve their eyesight. This subspecialty has the potential to boom and succeed in a way that we have not experienced before, but it will take efforts from colleagues who want to work together to build the market, to reduce the noise in the market, and to collaborate more. At this time, given the title of this editorial, you will be pleased to know that there are only two choices: (1) join the RSA and build the market; or (2) don’t join.

If you choose option No. 2 and keep doing what you were always doing, do not expect things to change.

— Arthur B. Cummings, MB ChB,
FCS(SA), MMed(Ophth), FRCS(Edin)
Associate Chief Medical Editor

1. Schwartz B. The paradox of choice. TED Global 2005. Accessed September 20, 2016.

2. Schwartz B. The Paradox of Choice: Why More Is Less. New York: Harper Perennial; 2004.

3. Alió JL, Krueger RR, Bidgoli S. The world burden of refractive blindness. J Refract Surg. 2016;32(9):582-584.

Ann-Marie Masterson, DipOptom, FAOI, PGDipCRS