Refractive cataract surgery: aiming for '20/happy' patients

For C. Ellis Wisely, MD, MBA, associate professor of ophthalmology at the Duke Eye Center, cataract surgery's evolution into a refractive procedure means success is no longer defined by 20/20 on paper but by whether the patient is "20/happy." In an interview with Ophthalmology Times, Wisely explained that patients can achieve 20/20 distance vision and still be unhappy—perhaps because they did not get the near vision they wanted—so surgeons must invest more work up front to understand what each individual patient is seeking.

Wisely introduces the full range of lens options—monofocal, extended depth of focus (EDOF) and multifocal—to every cataract patient rather than trying to "make a read" of who might be a premium candidate. He noted that a broad explanation can open the eyes of patients who never realized they valued spectacle independence, while patients who arrive requesting a trifocal IOL may turn out not to be good candidates, which the surgeon then has to explain. His goal is self-selection: he often asks patients whether they value independence from spectacles enough to pay out of pocket for it, a question that quickly determines how deep the conversation needs to go without disrupting clinic flow or chair time. Recent roundtable coverage in Ophthalmology Times reflects the same shift, noting that the expanding array of presbyopia-correcting IOLs has heightened patient expectations and made counseling around candidacy and outcomes more complex.

The hardest conversations, Wisely said, are the ones that happen after surgery—the patient who reads the chart at 20 ft but cannot see their phone. Assuming patients are fine with reading glasses is not a safe assumption in any consultation, he cautioned, and low myopes require particular care: having spent their lives removing glasses to read, they may not understand that a distance target trades away their near vision. On informed consent, he structures the conversation around three ranges of vision—distance, intermediate and near—using real-life examples such as driving, computer work and reading a novel, then maps lens categories onto those ranges. He urged colleagues to commit time to preoperative counseling, noting that when unhappy postoperative patients seek second opinions from him, the most common problem is not surgical execution but a patient who did not understand beforehand what they would get.

Wisely also observed that newer IOLs carry less risk of glare and halos and are opening the door to patients who previously would have been told they were not candidates: EDOFs are more forgiving of some corneal irregularity, making them an option for patients with conditions such as very mild Fuchs dystrophy, while some newer multifocals may be appropriate for patients with mild conditions such as glaucoma or early macular degeneration—though he cautioned the jury is still out to some degree and each lens must be evaluated separately. Finally, on timing surgery for borderline cataracts, he stressed clearly documenting whether a cataract is visually significant—which determines whether the procedure is cataract surgery or a differently billed clear lens exchange—establishing its impact on activities of daily living, and weighing the patient's goals and current spectacle status. Giving patients something they did not have before, he concluded, makes them much easier to please.