With each passing year, I become more comfortable addressing confrontational personalities and dealing with conflicting opinions and potential defensive posturing that may arise during the course of a consultation. Fortunately, these difficult encounters are few and far between, but as consumerism takes hold of health care delivery, anticipate steady growth! By no means are patients’ high expectations and the potential awkward encounters specific to laser vision correction or even refractive cataract surgery. Everything from providing glaucoma care to the way ocular surface disease is treated can come under assault. When a patient (client) is asked to make an investment (financial, time, and most importantly, in his or her health), their scrutiny is inevitable.

Wrestling with challenging questions can throw you off your game. If you are anything like me, the best response is likely to hit you on the ride home. By the time I get the door, my response almost sounds good, and then when my wife finishes tenderizing the meat for dinner, it is spectacular. In fact, it is all I can do to stop myself from calling the unfortunate soul and playing a mulligan.

In this moment of weakness, remember the emphasis should be on the “practice” of medicine. Next time you are asked a challenging question, take a deep breath, consider how you could have responded, and refine your answer.

Let’s review a few of the more memorable questions patients ask, and assess some of the possible responses.

1. Doctor, I know I have a cataract. But why should I have surgery?

Sandy Feldman, MD

You stated that you are dissatisfied with your vision and having trouble doing the activities like driving at night that you need to do. I examined your eyes and determined that new glasses and/or lenses will not help improve your vision, and that the cause is the cataract. That is how I know that your cataract is ready to be removed. Until a cataract interferes with your activities, it does not need to be removed. The decision is yours to make.

Lisa Brothers Arbisser, MD

There are no glasses changes, laser, or medicine that will restore your vision. Cataract surgery is the only choice to allow you to see the bright clear colors and details of the world. You’ll be amazed to see what you are missing since, as the clouding develops so slowly over time and you haven’t got a third perfect eye to compare to, the brain just keeps adapting and believes what it sees is reality. I expect you to be among the patients who, after seeing the world after surgery through the first eye, can’t believe how poorly the unoperated eye sees.

Realize that the cataract is just the normal lens of the eye becoming cloudy, and it very rarely interferes with the health of the eye. Whether I remove your cataract sooner or later we get the same good result. By the same token, you will never see better until you have surgery because the cataracts only worsen over time. Cataracts are the one aging change that we can often improve from your youth, because in clearing the cloudy window, we can, if you choose, focus the light better than your own lens ever did making you less dependent on glasses.

The only reason to wait is to postpone risk or, if your vision is adequate, wait for better technology which comes along every now and then. Based on your risk-benefit ratio, as we have discussed, you must be the one to decide if your vision is sufficiently bothersome to warrant improvement now, given the small, but unavoidable, statistical risk of surgery. Keep in mind that whether something is a 1% risk or a 10% risk, if it happens to you it is 100% but you have to take risk for the vast likelihood of improvement.

Here I show patients the old Timoptic eye model puzzle with the clear, creamy nuclear sclerotic, cortical and PSC removable lenses showing them the one that is most like theirs. I then show them their own lens with my slit-lamp camera direct and retro-illumination. This slit-lamp view on the monitor is particularly impressive to patients and family. When I show their nice clear black pupil in their first pseudophakic eye compared to their NS in the second eye when they are confirming that they have a complaint of daily living for their second eye surgery they are wowed.

David Goldman, MD

What I say: You should only have surgery if you’re having problems with your vision. Some patients feel uncomfortable driving at night or reading despite using glasses. In these cases cataract surgery can help. The only time I will tell you that you have to have surgery is if you can’t pass the driver’s test based on vision and you want to keep driving.

What I want to say: Because I’m sick of you coming in telling me your glasses need to be stronger. They can’t be made stronger. The only way you can see better is by having your cataracts removed.

Uday Devgan, MD

In fact, there is no rush to operate. If you are happy with your current vision and you don’t have any visual difficulties with your daily activities such as driving, using a computer, or reading, then my advice is to do nothing. Like the saying goes, “If it’s not broken, don’t fix it.”

All people, including me and even my kids, will get cataracts if we live long enough. The time to consider cataract surgery is when your current vision is not sufficient for your daily activities. This varies between patients: airplane pilots have high demands for their vision and often elect to have cataract surgery earlier whereas retired patients with a sedentary lifestyle may not be bothered by significant cataracts. For most patients, the concern is being able to pass the vision screening on the driver’s test and being able to see street signs. But ultimately, the choice is yours and there is virtually no downside, other than living with blurry vision, of delaying cataract surgery for a while.

Neda Shamie, MD

Unless the cataract is causing blockage of the outflow and increasing the pressure in your eye or advancing so much to make the extraction too difficult, you don’t need to have surgery, rather, it is a choice you make understanding that cataract extraction with lens implantation improves the quality of vision. This choice may be a necessity if your vision is hindering safe driving and the ability to tend to your activities of life (reading, work, etc.).

Daniel Chang, MD

If you are bothered by your vision, cataract surgery is a quick and painless procedure, and most patients see better within a few days—if not by the next morning. The neat part about cataract surgery is not only can it improve your vision but also it can reduce your need for glasses.

William Trattler, MD

It is your choice whether or not to have surgery. Since you are reporting difficulty with driving and other problems that are affecting your activities of daily living, however, it makes sense to perform cataract surgery and follow your eyes closely.

Karl Stonecipher, MD

That’s your choice not mine. I always ask the patient what they can and can’t do. If your current vision interferes with your daily activities of living then let’s proceed with surgery. Cataracts aren’t like a tumor; they don’t have to come out until they think its time. However, if your cataract interferes with your ability to drive, you may not be able to get your license renewed.

2. I was told I have astigmatism. Is it important for me to correct the astigmatism when I have my cataract surgery?

Sandy Feldman, MD

Astigmatism causes a diminution of the quality of the vision that you experience. It causes ghosting of letters, more starburst at night, and usually, will cause you to need glasses. If your goal from cataract surgery is to reduce your dependence on glasses or contacts, then correcting astigmatism is important for you. 

Lisa Brothers Arbisser, MD

After explaining astigmatism and how it is fixed I then say: Although you will have the same quality of vision with glasses on whether we address your astigmatism or not, with glasses off your vision will be blurred at all distances. Even if you enjoy wearing glasses, and you can still wear them as much as you want, you might forget to put them on until you have to read and most likely you won’t be dependent on them. If they break, you can drive to the store and pick up some readers until a new pair is made, instead of having to be driven around. Toric lenses are one of the few technologies that have no added risk other than to your pocketbook. It is possible that you might spend the money and still need some glasses or, the rare event that the result isn’t optimal, you would have the choice of another surgery to get closer to perfect. It’s up to you whether this freedom from glasses is valuable to you. If I were in your place you couldn’t drag me to surgery without fixing my astigmatism at the same time as cataract surgery.

David Goldman, MD

What I say: If the astigmatism is not corrected, you will need glasses after surgery to see far away and near (bifocals). If you don’t mind that, you don’t need to have the astigmatism corrected. If you do have the astigmatism corrected, you would be able to see far away/drive your car without glasses and just use over-the-counter cheaters for reading.

What I want to say: It’s not important at all. Sure you could have lenses implanted to correct the astigmatism so you could get around without glasses for a lot of things, but it maybe it makes more sense to spend a couple hundred dollars every few years on new glasses instead that you’ll depend on to get around all the time.

Uday Devgan, MD

Cataract surgery is just to correct the cataract whereas refractive surgery is to provide a specific refractive outcome, which can mean fixing your astigmatism at the same time or making your vision sharp without glasses at distance, near, or both. If it is important for you to minimize the use of glasses after cataract surgery, then let’s talk about correcting the astigmatism at the same time. If you love wearing glasses, then let’s just fix the cataract and you can get a new glasses prescription to address the astigmatism.

Neda Shamie, MD

Correcting astigmatism at the time of surgery will allow for better uncorrected vision. Again, this is a choice you make and one that empowers all of our patients in taking charge of their visual outcome and potential.

Daniel Chang, MD

You can choose to correct your astigmatism inside of your eye—with a lens implant, or outside of the eye—with glasses. When I correct astigmatism at the time of surgery, most of my patients are able to drive and to see the TV without glasses. Other than not having the deal with the frustration of glasses, fixing the astigmatism inside of the eye may leave you with better overall quality of vision.

Karl Stonecipher, MD

Astigmatism is really simple. Your eye is shaped more like a football than a basketball. If I correct it, then you are less likely to need glasses for distance vision after we are done. If I don’t, then you will be wearing glasses when I am done.

So you have to ask yourself, do you want to be glasses free at a distance when you are done? If the answer to that question is yes then are you willing to pay extra for that? Unfortunately, the correction of astigmatism is not a covered expense by your insurance or Medicare, and instead it is an out-of-pocket expense.

3. Why do I still need glasses to use my computer even after I have received a multifocal implant?

Sandy Feldman, MD

It is important that we spend a lot of time educating you about the benefits and risks of the available implants. The world has many different distances, and at the present time, there is no perfect solution that provides great vision at all distances. Now, with iPads, computers, electronic readers, and smartphones, as well as books and driving, the demands on our eyes are greater. We doctors want manufacturers to improve the lenses that are commercially available. And they have a tough job, imitating nature when we were young!

Lisa Brothers Arbisser, MD

Before surgery when they choose a multifocal I say: Keep in mind that you are not a widget and I am not God. We are using the most modern technology on the planet, and still cannot guarantee any individual they will never need glasses for any task. We can guarantee you will need them if we don’t choose this route. The vast majority of patients will be free of glasses only with the choice of multifocal lenses. We cannot make your eyes like perfect eyes of a 15-year-old but rather mimic this function by dividing light rays into two images with diffractive technology. I show them the little ridges on the IOL model that I have. Therefore there is not as much light in either image. You will never be aware of seeing two images at once but will see a slight blur circle around the sharp image you are looking at, most noticeable as a halo around point sources of light. It is up to the brain to tune out the noise and tune in the information. This neuroadaptation happens best with the same visual system in both eyes so, except in very rare circumstances if all goes well with the surgery in one eye, assuming you have a complaint of daily living due to cataract in the other, you will have a multifocal lens in both eyes before you see your best. Some patients hardly notice halos even from the beginning. Some patients can be bothered at first. A very rare patient may not adapt, even over time, and be unhappy enough to require further surgery. If your primary goal is to have good vision without glasses, despite the slight compromise of quality of vision that multifocality, by necessity, causes, then I recommend the multifocal lenses to you. Let’s talk about the two kinds of multifocals currently available in the US today.

We need vision at three distances; far, (driving, golf) intermediate, (computer or reading music) and near (reading). Since we only get two eyes which is why blended vision with monofocal lenses can be used for the first two only and will require glasses for fine print, threading a needle and driving in challenging circumstances where two eyes are better than one. Though this strategy only minimally interferes with depth perception when glasses are off, the quality of vision in each eye is the best we can offer. Multifocal lenses on the other hand allow you to see with both eyes at once providing the best depth perception and giving you the best range of vision possible from distance to near without glasses. There are two kinds of multifocal lenses available in the US with differing strong points. Depending on your particular lifestyle and needs one may suit you best. Both are at their best for distance and near compared to intermediate but one has a greater intermediate range and the other better near in dim light.

Then I go through the specific lenses. What questions do you have and what choices seem right for you?

David Goldman, MD

What I say: The Tecnis Multifocal lens offers great distance and reading vision but not as good intermediate. The other multifocal, the Restor, has great distance and intermediate but not as good reading vision. In the end, we can’t give you the vision of an 18-year-old. However, because your distance and reading vision is excellent, you can go for most of your day without glasses. For driving, using your phone, the few times when you use your computer, etc., you can keep a pair of +1.50 D readers nearby to use.

What I want to say: Because that’s not a computer, it’s a toaster. And I didn’t put in a multifocal lens because you said you weren’t paying for it and you have terrible macular degeneration.

Uday Devgan, MD

There is no man-made lens that is as good as the young, human lens. Same with other body parts like titanium hip implants and prosthetic heart valves. Nothing beats being young, and since there’s no fountain of youth, we’ll have to make some compromises.

We have very good lens implants that can give a wider range of vision without glasses, but there may be some tasks such as those in the intermediate range like computer or very close range like removing a splinter, where glasses would be needed.

Neda Shamie, MD

No IOL is perfect, and even though multifocal lenses offer a more complete range of vision (near to middle to far), the midrange tends to be less in focus and may require “cheaters” for optimal vision.

Daniel Chang, MD

I discuss this with every multifocal IOL patient prior to surgery, specifically asking if they do much computer work and emphasizing the issue if they do. During the discussion, I physically place my hand in front of their face showing the difference between “near” and “intermediate” vision. I then tell them that if they have difficulty with the computer after surgery, they have three options: (1) move closer to the screen, (2) make the font larger, (3) wear computer glasses. I then say that if someone needs glasses after multifocal lenses, this is the one range where they may need them. Postoperatively, I do have patients frustrated with this issue, but I never have patients surprised by this issue, so I never get this question.

Karl Stonecipher, MD

Mine never do!

As we discussed before surgery, your range of vision at distance, intermediate, and near is an issue. Like we discussed, I am going to get you out of your glasses for 85% to 90% of your routine activities. The other 10% to 15%, you are going to need something. Unfortunately our present lenses can’t match what God, Yaweh, or Allah gave you… (of course, depending on their religion).

4. You look like you are still in high school. How many surgeries have you done?

Sandy Feldman, MD

Thank you! Well, now I know you need your cataract taken out. If you could really see me, you would not say that!

Lisa Brothers Arbisser, MD

Maybe you’ll see my grey hair better after cataract surgery! I’ve been operating on cataracts for more than 30 years and have done around 25,000 cases, so I deserve my grey hairs.

David Goldman, MD

What I say: About 10,000 cataract surgeries, and when I was at Bascom Palmer, I was the second highest volume surgeon in all the facilities for about 5 years. That said, I know I have a baby face and if you prefer a surgeon with a few more “grey hairs,” I am happy to recommend a more senior surgeon. No matter what, you should feel comfortable with your surgeon.

What I want to say: Actually, you’re just really old. I mean, when you were my age Lyndon Johnson was president. Lyndon freakin’ Johnson. Think about it.

Uday Devgan, MD

I’ve done many thousands of cataract surgeries, and while I wish I was still young, I’m 44 years old, and the first cataract surgery I did was 17 years ago. The most important thing that I can tell you is that I am passionate about my work, and I deliver the same high level of care to my patients as I would want for my own eyes.

Neda Shamie, MD

Thank goodness for Botox! I have performed thousands of surgeries … do you need an exact number? Probably the more important question you should be asking is, if my complication rate is at or below the acceptable levels and if complications were to occur, would I be able to manage them properly, or have access to resources to minimize a chance of a poor outcome.

Daniel Chang, MD

Thanks, (I don’t hear that so much anymore). I have done over 5,000 cataract surgeries, but I only do them one at a time. When I’m operating on you, your eye is the only one that matters.

William Trattler, MD

This definitely happens, followed by the question, are you a single doctor and can I fix you up with my granddaughter?

Karl Stonecipher, MD

I appreciate the compliment. In fact I have done more than 75,000 surgeries total. Yes, I do sleep, but I also work a lot. Hey, what can I say, I started early and you should see my mom, she looks like she’s in college.

5. My mother had cataract surgery 20 years ago, and she doesn’t have to wear glasses. Why do I have to pay extra in order to be free of glasses? What kind of game are you playing?

Sandy Feldman, MD

The demands of patients have gotten a lot greater in the past several years. Now, patients want to be glasses-free for lots of activities, like reading, using the computer, and driving. Unfortunately, we cannot get it perfect for one distance 100% of the time, let alone, the fact that there is no single option that is perfect for vision all distances. Believe it or not, we only achieve 20/20 vision about 60% of the time after cataract surgery. That means 40% of people will likely need some sort of distance glasses and that does not even include reading glasses. We will do our best to achieve great distance vision no matter what choice you make or what you pay!

Lisa Brothers Arbisser, MD

Does she drive at night in Chicago or read fine print in contracts all day? Seriously, her needs may not be as great, or she may have a blended vision result, and if she had no inborn astigmatism, this may be possible. I have given patients the ability to function fairly well without glasses for most daily activities with a blended vision technique for generations in this community without charge until recently. We are so much more likely now than we were then with all the technology we have available to achieve our goals. Though Medicare covers cataract surgery, it does not cover refractive procedures or the testing done to achieve refractive goals and, with the cost of providing quality of care rising and the fees for service from Medicare continually falling, we cannot afford to give refractive services free. Happily society believes you have the right to see, but it is a personal responsibility to pay for the privilege of seeing without the aid of glasses. Otherwise, society might run out of the money to pay for treating heart attacks. Let’s hope that doesn’t happen anyway!

David Goldman, MD

What I say: She likely has a version of monovision where one eye is seeing far away and one is reading, or she may not see a crisp 20/20 but is happy with things slightly blurred not needing glasses. I can do monovision for you as well, but since you now have cataracts, I can’t demonstrate what it would be like after surgery. If you do not tolerate the monovision, you will either have to wear bifocals all the time to balance the eyes or have LASIK to balance the eyes. LASIK is not covered by insurance.

What I want to say: Really? Bring your mother in here and let’s see how good her vision really is.

Uday Devgan, MD

When it comes to eye surgery, I can assure you that there are no games. My goal is to tailor the cataract surgery to the specific patient and no two patients are alike. In a small percentage of patients, there is no preexisting astigmatism or other focusing issues and the entire rest of the eye is perfectly healthy. These patients may get great vision after a simple cataract surgery. However, for most patients, delivering the widest range of sharp vision without glasses requires refractive procedures and/or specialized lens implants at the time of cataract surgery.

Neda Shamie, MD

She may have been given monovision or left slightly nearsighted. She may also not have the same demands on her vision as your generation does…20/40 uncorrected visual acuity for grandma may be good enough for her, but for our baby boomers seeking 20/15 uncorrected visual acuity, advanced cutting-edge cataract surgery with optimized refractive outcomes is in greater demand.

Daniel Chang, MD

Inflation.

How clearly is she seeing things? Different patients have different visual demands, and some people will tolerate some blurriness for the convenience of not wearing glasses. Some people may have monovision, which I explain, but I don’t like to do monovision for people who haven’t already had it before. Regardless, the only reliable way to get you out of glasses both for distance and for near is with multifocal lenses.

Karl Stonecipher, MD

Great point. I operated on my mom and implanted a standard lens, and she doesn’t wear glasses for anything except for some of her near activities. Each patient’s eyes are different; some have astigmatism and some don’t; some are long and some are short. But more importantly everyone’s hobbies and habits are different, so I need to know what you do that you call work and what you do that you call play. If we can, we will use a standard lens. If you fall outside the range or have different requirements or anatomy, then we may offer you one of the specialty lenses. It’s like a patient said to me the other day, “Hey doc, all I do these days is sit around and watch Judge Judy all day. I am ok with glasses.” His wife replied, “If we go for the specialty lenses, do you think you could get him to do something productive.”

6. My friend had bladeless cataract surgery. Do you do laser cataract?

Sandy Feldman, MD

Yes. Of course, I use modern technology to perform precise surgery. The laser enables more precise, gentler surgery. What I really like is the precise opening in the front lens capsule with the laser. It is more perfect every time. I hate to admit that it does a better job than I can do as a surgeon, but it can! It adds precision that manual opening does not have.

What I also, really like is that it images your eyes in 3-D before surgery, and enables me to get a different clearer picture of your lens and what it will be like to take out. Some cataracts are dense and small, others are huge. I cannot always tell the size by looking through the microscope. The laser also does a great job of softening the lens further, which makes it easier for me to take out.

Lisa Brothers Arbisser, MD

Yes I do. I recommend it to you if you want the most modern procedure on the planet and you want the greatest likelihood of independence from glasses with one surgery. Despite my 30 years of practice, and I practice well and can offer you wonderful procedure done by hand, no one can be as reproducible and accurate as a computer guided laser customized for your eye.

David Goldman, MD

What I say: I don’t do laser cataract surgery. I use microincisional high-frequency ultrasound to remove the cataract. Ultrasound is sound waves whereas laser is light waves. My technique takes much less time than the laser, the results are exactly the same, and the recovery may be a little faster with my technique.

What I want to say: That is what I want to say.

Uday Devgan, MD

Yes, we are fortunate to have two of these laser platforms at our surgery center. But let me assure you that the laser is simply a tool, and it still requires a surgeon with skill, dexterity, and judgment to deliver the best visual outcomes.

Neda Shamie, MD

Yes I do routinely, as I believe in its benefits.

Daniel Chang, MD

No. It would cost you more, and from the information available, I see no evidence that it would help you see any better. My results without the laser is better than most published laser cataract surgery outcomes.

William Trattler, MD

Yes I do. Where did you hear about bladeless cataract surgery?

Karl Stonecipher, MD

Absolutely. In my hands, it is safer and has better outcomes. The complaints that I hear from surgeons who don’t use are that it costs too much and it takes them longer to do surgery with the laser. As for my patients and me, I always want the best, safest, and most productive procedure, even if it takes me a little longer to do.

7. Ever since my LASIK, both eyes burn and tear at the end of the day. My computer screen gets blurry, and I now need glasses. Why do I have to wear glasses again? Fix it!

Sandy Feldman, MD

How long ago did you have LASIK? Unfortunately, since then, we cannot stop your age, from changing your eyes! Although LASIK lasts a long time, we continue to age and it does not stop the aging process. Reading glasses are a function of the aging process, which causes our arms to not be long enough and usually, happens between 41 and 45 years of age. You are 48, so you are lucky that this did not happen sooner!

Most of us who work on a computer experience dry eyes. Let’s look at your eyes and try to make it better! There are many reasons for dryness, especially as we age. One tip I give to all people who work on a computer, is the 20/20/20 rule: after 20 minutes of reading, look up 20 feet away for 20 seconds and blink 20 times. This will help to move what tears you make around.

David Goldman, MD

What I say: Staring at a computer screen all day we tend not to blink as much. Because of this, your eyes are drying too much. I’m going to place you on a tear regimen that should fix everything.

What I want to say: You have a very complex issue with your ocular surface. I am going to send you to world expert Bill Trattler who will be able to make you perfect right away.

Uday Devgan, MD

Youth is wasted on young people because they simply don’t appreciate what they have. When we’re young, under age 40, there is an amazing ability for the eye to focus from far to intermediate to near. This ability diminishes with age and it’s the reason why people who had “perfect eyes” their entire life suddenly find themselves using reading glasses at age 45 to 50.

When you had LASIK as a 38-year-old, that surgery gave you the great vision of a 38-year-old who didn’t need glasses. Now that you’re 45, you have the eyes of a perfectly healthy 45-year-old… and you need readers.

Neda Shamie, MD

Tear film dysfunction can impact the vision quality and stability as well as the refractive outcome. As for the need for glasses, it may be because of the tear film or the development of presbyopia, which can occur with age.

Daniel Chang, MD

I tell every LASIK patient that his or her eyes will be drier after surgery. As the day goes on, your tear film evaporates, so your body tries to compensates by flooding your eyes with tears. When you use the computer, your eyes blink less, resulting in the same problem. This can also blur your vision. Using frequent artificial tears will help to refresh and to soothe your eyes for a sustained period of time. There are prescription eyes drops that can be used as well.

William Trattler, MD

It would be my pleasure to help solve your vision problem. Surprisingly, the cause for your reduced vision is not due to your LASIK surgery not lasting. Rather, it is due to the development of dry eye, which fortunately is treatable. If we fix your dry eye with prescription eye drops, punctal plugs, or other treatments, over time, I would expect that your vision would improve.

Karl Stonecipher, MD

You sound like me except the part about glasses. I had dry eyes before my LASIK procedure, and I have dry eyes after my LASIK procedure. In a recent study we showed that many of my patients come in with dry eye-related contact lens issues. So that is why we treat dry eyes aggressively both prior to surgery and after surgery. Now, let’s look at where the problem is for you and your visual issues. Is it distance? If so, we can work it up and if the anatomy of your post-LASIK eye warrants, we can do an enhancement. Is it intermediate or near vision? We need to see what the issues are related to your near vision. Is this an age-related issue or something else? Whatever the case, we are here for you. Many of our patients come from referral through other patients. We want you to see well so you too will recommend laser vision correction to others. Let’s get started.

8. Since you placed a multifocal IOL in my left eye, I am seeing halos when I drive. What are you going to do about it? I don’t know if I want my other eye treated.

Sandy Feldman, MD

With this question, it is important to assess the function and the satisfaction level of the patient. Does he or she see halos but can function? Or does he or she see halo and this is affecting the quality of their lives. Predicting a patient’s satisfaction level with multifocal lenses can be difficult no matter how much explanation was done before. Using tools to show a patient what was discussed before surgery is helpful, and having data on your patients who were dissatisfied early but recovered is also helpful.

Lisa Brothers Arbisser, MD

A lot of what I say preoperatively preempts this question (see answer to question 3). When patients are sufficiently unhappy with the first eye to voice concern for proceeding with the fellow eye it is a very vexing problem. They already know they won’t see their best, and I remind them, even while undraping at the completion of first eye surgery that, while they may be at their best in this eye almost immediately, they won’t see their best until they have the same visual system in both eyes. I pencil in the date 1 week later, if possible, for multifocal patients’ second eye when we book the first. We confirm that on day 1 or at the 5-day postop visit, assuming we can confirm a complaint of daily living for the fellow eye. So if they are unhappy with the first, we must find out why. If the lens is centered, the topography and refraction show we are close or perfect and there is nothing apparently wrong then I give this explanation:

You were born yesterday with a foreign visual system and most brains adapt best when it is in both eyes. There is nothing wrong with the health of your eye and there has been no surgical complication. I show the patient their uncorrected near vision in the operated eye and what it would be like without the multifocal by putting a -2.50 loose lens in front of their eye as they look at the J2 line so they understand what they would see if they hadn’t chosen the multifocal. I always show myopes (who are the ones most likely to be unhappy on day 1) how their near vision may be better than the multifocal but I say look at your uncorrected distance vision (alternately cover each eye while they look at the distance chart). I explain that one and one is more than two when it comes to multifocal vision, especially at near.

Although very rare, I take seriously the fact that multifocal vision may not be acceptable to your brain, but we haven’t given you a chance to really tell until we do the other eye. This may be the only time in medicine when we say, if you don’t like what we did the first time you may love it when we do the same thing the second time. So, your choices are:

•Wait to decide (but you will never be happy, and possibly increasingly unhappy, until you decide what to do).
•Decide now you will not be able to achieve the goal of glasses independence and take the risk of lens exchange for a monofocal lens knowing that it will take three surgeries for you to see well again. At this point I explain the risk of another intraocular intervention, tell them how the lens is within the delicate bag and must be extricated and replaced, explain the risk of visual loss and potential for placing a lens in a less reliable place in the eye.
•Go ahead with the plan for a multifocal in the second eye.
•If we choose number 3, to proceed with the multifocal IOL in your right eye, I hope and pray you will find that, like the vast majority of the millions of people with multifocal vision, and like the literature predicts, you will then be happy, even delighted with your vision. In saying this, you must know that there is a small chance that you still won’t neuroadapt and be one of the very rare individuals who requires an exchange in both eyes (four surgeries) before you achieve your best outcome, albeit with glasses.

I leave it to you to decide which to do or to get a second opinion if you wish. There are two reasons for second opinions: one is if I don’t know what to do and then I insist. This is not the case here. The other reason is if you are not confident and want to hear someone else tell you his or her opinion. I have no ego problem with this as my goal is for you to have peace of mind and get the best result you are capable of. I can’t remember the last patient who wanted a second opinion or the last patient who, in this circumstance, chose an exchange.

David Goldman, MD

What I say: The halos are expected because of the way the lens works, but will greatly improve over time.

What I want to say: Do you not remember me telling you that you may experience some halos with the multifocal lens? I said “nothing’s perfect” and you were like “yeah yeah I just can’t wear glasses after surgery—no way”?

Uday Devgan, MD

The multifocal lens gives the ability to see near and far from the same eye but it does so at a cost: The light is split and there can be glare, halos, and a loss of contrast. The vast majority of patients say that the trade-off is worth it since they have so much freedom from glasses. Occasionally, about 1% of patients with a multifocal lens request to have it replaced with a standard lens. The halos disappear but so does the near vision.

Neda Shamie, MD

If it is true halos you are seeing, it may be your tear film or opacification in the capsule in which the IOL is placed. We can aggressively treat the tear film problems and in many cases resolve the visual complaints. As for the capsule, I would hesitate doing laser YAG unless I am sure that is the main problem and a lens exchange is not a possible next step. I would put off operating on the second eye until these issues are addressed. Sometimes though the “halos” you describe are actually the “rings” around light seen with multifocal lenses, and most patients learn to tolerate and ignore them with time.

Daniel Chang, MD

My approach is to take the initiative on the halos issue. During preoperative counseling, not only do I describe halos, but I also show every potential multifocal patient a set of night vision simulation pictures demonstrating halos and their subjective improvement with time. I also ask every multifocal patient on the postoperative day-1 visit about whether they saw halos the night of surgery. My patients are therefore never surprised at halos. Even so, some are still frustrated by them. In this case, I encourage them that halos will improve with time. If they continue to complain or seem unhappy, I pull out the same picture from preop and ask (1) if they remember that picture and (2) how the halos compare to that picture. Rarely are their symptoms worse than the picture that I use, but regardless of their answer, I show them the “improves with time” picture, stressing that it could take weeks to months. If a patient is unhappy with halos and wasn’t expecting them, then it is extremely difficult to appease them. You simply can’t “get behind the 8-ball” on this issue.

Karl Stonecipher, MD

As you will recall, we discussed this issue prior to surgery. The primary three things we see exacerbating this issue are: (1) residual refractive error primarily astigmatism, (2) dry eye disease, or (3) epiretinal membranes. We checked on number (3) by getting that OCT prior to surgery and finding it was normal. As for (1) or (2), let’s examine you and see if those could be the problem. I want to reassure you that most people will adapt to issues related to halos around lights. I don’t want to belittle your problem, and I agree we shouldn’t do anything with the other eye until you are satisfied with this one. 

9. I had a hole placed in my left eye to treat my glaucoma. I understand there is a new device that can be placed in my eye to lower pressure when you remove a cataract. Insurance only pays for one device, and I really don’t want a hole in my other eye. Can you place two devices?

David Goldman, MD

What I say: No.

What I want to say: All depends. How many holes would you like in your eye?

Daniel Chang, MD

No.

William Trattler, MD

The Internet is a wonderful thing, and I am happy that you spent time researching options before arriving to see me. The Glaukos iStent is a wonderful device that we use at the time of cataract surgery to help lower the eye pressure postoperatively. We can only place one iStent in the eye at this time.

Karl Stonecipher, MD

I wish I did everything but I don’t. There are not enough hours in the day, and I already operate 4 to 5 days per week. I have this great partner, Dr. Whitaker, who is an expert in glaucoma; that is all he does. Let’s get you to see him and find out what’s best for your particular issues.

10. I was told I have early cataracts, and I am worried about what may happen to my coverage with all of the health care changes coming. Can you take my cataracts out now?

Sandy Feldman, MD

We make a decision to remove cataracts based on their size and if they are affecting your activities of daily living. If your cataracts are small, insurance will not usually cover them today. 

David Goldman, MD

What I say: We can only take out your cataracts when they are affecting your vision.

What I want to say: Sure thing. Let me just have my technician recheck your glare vision.

Uday Devgan, MD

See my answer to question 1. Plus I add, In certain patients with a large glasses prescription and early cataracts, a decision can be made to do an early cataract surgery but primarily for the purpose of reducing or eliminating the glasses. This would not be covered by any insurance plan.

Neda Shamie, MD

Unless the cataract is deemed visually significant, I cannot justify the risks of cataract surgery.

Daniel Chang, MD

Who knows what changes are coming? And then there are taxes…

Let’s make our decision on your medical needs first, then we can take the financial aspect into consideration.

Karl Stonecipher, MD

We never want to do anything based on the issue of money. As you know, there are inherent risks to cataract surgery and what if—albeit rare—something happens? We are going to be kicking ourselves for pushing the issue when you don’t have a problem the interferes with your daily activities of living. 

11. You told me I may have blepharitis. I think I know what it is… but why should I pay to have the equivalent of a hot potato placed on my eyelids?

Sandy Feldman, MD

Blepharitis is a chronic condition that can be treated successfully with a number of different treatments. I would recommend that you try the noninvasive, least expensive methods first. If you have tried them, and the condition is still affecting your life and leaving you frustrated, a new therapeutic option that might help. Then, I proceed to educate the patient.

Neda Shamie, MD

The LipiFlow is a targeted and effective treatment with known benefits. I would recommend it after other conservative measures have failed or when the severity of your meibomian gland disease justifies it as an early therapy.

Daniel Chang, MD

Good question. Have you every heard of intense pulsed light therapy/broad band light?

Karl Stonecipher, MD

I agree at this time in your process. Although the technology works well in some individuals, it is very expensive. One of the items I am using with success is the Rhein Fire and Ice Mask. Let’s try it first and see if it works. If not then we can discuss the other options available.