Of premium procedures and high hopes

Managing the expectations of these cataract patients requires a two-pronged approach.

For surgeons who offer premium cataract procedures, managing patient expectations is an inextricable part of the job. Unfortunately, we were trained to be surgeons rather than psychologists. As ophthalmic technology has advanced, this lack of proper expectation-setting with patients can make us our own worst enemies when it comes to dealing with patients and helping them obtain the vision they desire.

From the outset, patients arrive at the office already in an unrealistic mindset of what to expect postoperatively. Many patients even ask immediately at the end of the surgical procedure, while still on the OR table, why their vision isn’t perfect yet — despite waiting too long in the first place to have their cataracts removed. And with so much information at their fingertips about the potential benefits of femtosecond lasers, premium IOLs, microsurgery and advanced pharmaceuticals, the odds of setting realistic expectations are stacked against us before they even walk into our practices. Factor in the higher fee associated with premium procedures and the need to help patients understand the IOL selection process, and the odds against us shoot up even higher.

The question for us is, how do we regain control of the situation? If we give information to patients, then how much do we give, what kind do they need preoperatively and how much will just “overload” and confuse them? What information do we need to help them obtain the vision that will make them happy? Our patients must be educated beforehand that good surgery may involve a complication, and resolution of that complication may require a second and even third procedure. If they understand that, the final result is usually satisfaction.

To find that happy balance and foster realistic visual goals in our patients, I have found that it is critical the surgeon take a careful look at both the personal and the clinical for each patient — that is, conduct both a subjective and objective analysis.


This subjective and objective analysis is vital in creating appropriate expectations for patients. While the two categories can be difficult to separate, below I try to break down each from both the surgeon and patient perspective.

Subjective analysis is subjective in terms of symptomology. This category includes dysphotopsias, glare/halo, dry eye or ocular surface disease, and lifestyle visual desires from a vocational and avocational perspective. Personality interpretation (ie, which patients really need “Special K” or should not even be operated on) and lifestyle questionnaires also fall under this heading.

Objective analysis should include a discussion of enhancement approaches postoperatively, the potential need for YAG laser capsulotomy and an explanation on ocular confusion (second eye syndrome). Another important topic is the vast array of available diagnostic testing (tear osmolarity, biometry, topography, tomography, OCT imaging of the macula and/or anterior segment, angle kappa/alpha quantification, meibomian gland imaging, objective scatter index measurements, higher-order aberration analysis and AI-supported software) to match patient data with specifications of the various IOLs we currently use.


When seeing a patient referred in for cataract surgery, you can save valuable chair time by requesting the patient’s intel from the referring optometrist or primary care physician. The referring OD can offer valuable information on whether the patient does a lot of driving day or night, loves to read or is devoted to a hobby such as golf.

In my practice, we sell premium options based on lifestyle — “Basic” (the cataract is removed but the patient will wear glasses full-time postop for all levels of vision functioning ), “Legal to drive” (a category created by Jim Loden, MD; it delivers legal driving vision OU without glasses; glasses are required for intermediate- and near-vision tasks) and ”Forever young” (a category created by my practice, it involves a presbyopic IOL).

We use this model because most patients do not understand terms such as astigmatism, presbyopia, monovision, higher-order aberrations, angle kappa/alpha and the like. By allowing the patients to choose his or her lifestyle preference, potential postoperative complaints are limited. There’s no informing the patient of the specific IOL you intend to implant ahead of time, with the patient then going online to read every possible side effect of that IOL and coming in to spend 20 minutes in the exam lane claiming he or she is experiencing all those side effects.

Instead, I focus on providing a lifestyle of vision and use all means at my disposal to obtain that end result. My practice includes enhancements as part of patients’ premium IOL package. For example, if a residual refractive error persists even after YAG capsulotomy, the appropriate laser vision correction procedure (PRK, LASIK, SMILE) is offered as part of the fee for the lifestyle option chosen in order to get that patient to the desired refractive error.

Typically, for Symfony toric and nontoric IOLs (Johnson & Johnson Vision), the preferred refractive target is plano in the dominant eye and -0.25 sphere in the nondominant eye; for the ActiveFocus and ActiveFocus Toric IOL technology (Alcon) it’s -0.25 sphere in the dominant eye and -0.75 sphere in the nondominant eye. If these targets are not reached postoperatively, some form of enhancement may be required, even after the YAG capsulotomy. Again, these “enhancement” possibilities must be discussed preoperatively as part of the appropriate expectation process. AI software developed by Vivior, which analyzes patient data for optimal IOL selection, is gaining popularity and could be the next generation of managing patient expectations. I look forward to integrating this technology into my practice in the near future.

My biggest preoperative expectation discussion with patients is the one about dry eye. I have found that most patients do not believe they have this condition preoperatively, but a host of studies show that most patients have objective signs of dry eye prior to cataract surgery — despite being asymptomatic. Utilizing dry eye questionnaires in conjunction with lifestyle questionnaires (my practice uses a modified Dell format) will yield information critical to knowing the condition of the ocular surface before surgery, especially as it affects activities of near vision such as computer, laptop and smartphone use. The modified Dell questionnaire not only helps identify vocational and avocational needs of a patient, but it also has the patient choose his/her own personality type from easy-going to obsessive compulsive.

This information informs the surgeon of the patient’s risk of dry eye before choosing an IOL. By diagnosing and discussing ocular surface disease and abnormalities preoperatively, we will avoid having our perfect cataract surgery blamed for the patient’s ocular surface condition postoperatively.

Lastly, using objective scatter indexing (OSI) with HD Analyzer technology (Visiometrics) to quantify the quality of vision preoperatively not only helps obtain insurance coverage for surgery but presents to the patient the severity of his or her visual deficit preoperatively. Also, this OSI number quantifies postoperatively the severity of any ocular surface issue and/or posterior capsular opacification, for example.


This obviously overlaps with some material stated in the section above, but attention to preoperative diagnostic testing in a quantitative analysis is critical for optimizing the patient’s correct IOL selection and desired visual outcome.

For example, placing a multifocal IOL in a patient with an angle kappa/alpha higher than 0.75 μm typically leads to a dissatisfied patient. Here are the crucial diagnostics to run and the consequences of omitting them:

  • Meibomian imaging. Placing premium IOLs of any type in a patient with little to no meibomian glands seen via meibography typically will lead to a poor visual performance postoperatively, especially with near-vision tasks.
  • Tomography. Use tomography to properly discern before surgery whether an irregular astigmatism is caused by an epithelial basement membrane corneal dystrophy. Failing to do so can result in a less than desirable postoperative visual outcome.
  • Corneal topography and epithelial mapping. Skipping corneal topography in conjunction with corneal epithelial mapping in borderline cases may miss forme fruste keratoconus or pellucid marginal degeneration preoperatively, and thus prevent a true way to enhance a patient post premium IOL placement if the refractive target is missed.
  • OCT. Imaging the macula preoperatively with OCT is critical to ruling out any disease process such as epiretinal membrane or macular hole pathology, which would definitely leave a patient very unhappy with a premium IOL.


Managing patient expectations has evolved from simply telling patients they will need a new pair of glasses after surgery to having to talk to patients angry over having to wear glasses after surgery — the latter is usually because they did not choose an option that would have eradicated glasses or at least reduced their dependence significantly. As part of the patient education process, we must remember to tell them they are no longer 20 years old and that darn chronic “aging” syndrome will always progress.

Premium cataract surgeons must take the responsibility to set expectations appropriately and live by that wise adage “under promise and over deliver” to eliminate exam lane exhaustion as much as possible. OM

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