When asked to write about patient psychology relating to multifocal IOLs, I decided to turn to the scenario I hear frequently from refractive surgeons. Two patients are given the same extensive education and preoperative counseling. They both articulate an understanding of reasonable expectations for their outcome. They both voice motivation and a willingness to accept a possible compromise in terms of visual quality postoperatively (eg, halos and glare) and a neuroadaptative process that may last longer than expected. Despite similar subjective and objective outcomes, however, one complains bitterly of disappointment in the procedure's results, whereas the other one seems satisfied. Why?

The answer involves not only the psychology of the patient, but also the psychology of the surgeon and staff. Psychological factors influence patients' acceptance of the tradeoffs associated with the implantation of multifocal IOLs, and you and your staff need to sharpen your psychological skills to improve the success rate for this procedure.

THE ROLE OF EMOTIONS
Neuroscience shows that emotions affect a person's decision-making process. Emotions play a role in how patients process and incorporate information. The memory of facts is enhanced through learning in association with an emotion. Emotions play a role in whether patients choose to undergo surgery, and they influence how patients perceive their subjective surgical outcome. Emotions also impact whether patients will effectively cope with any results they deem negative, and the degree to which they will respond to postoperative reassurance from you.

Because emotions play an important role in patients' satisfaction, you and your staff need to learn how to develop a positive emotional connection with each surgical candidate. Establishing such a relationship early is just as critical as a careful examination and extensive preoperative counseling. Positive associations make it more likely that patients will choose you as their surgeon and refer other potential patients to your facility. Achieving a solid patient/doctor relationship helps patients to share any concerns they have throughout the surgical experience. When you and your staff establish and maintain that positive emotional link with your patients, they will be more accepting overall of your reassurance regarding outcomes they perceive as negative.

NEGATIVE OUTCOMES
Psychosocial Factors
A study of patients' visual experiences and satisfaction after wavefront-guided LASIK compared the postoperative change in vision scores with the subjective perception of visual change. The investigators found that patients were more expressive about decreased vision than about aspects of their vision that improved by the same amount.¹ The study also found that men more frequently reported visual symptoms and complained more strongly about their vision at night than women, even though the changes were the same as those of the women.

That patients were more expressive about visual decline than improvement is not surprising. From the standpoint of basic survival, it makes sense for human brains to prioritize negative information over positive information. The question remains, however, as to why some patients complain more strongly and seem less able to cope with a compromise in visual quality or side effects than others. Psychosocial factors such as coping style, personality traits, the presence of psychiatric symptoms, and resilience most likely play a role.

Assessing Personalities
Many experienced surgeons recommend considering a candidate's personality when evaluating his candidacy for surgery, but the method for doing so is rarely discussed. Limited exposure to patients preoperatively and a lack of formal training in behavioral assessment make accurate judgments difficult.

My literature search found no published peer-reviewed studies that used validated psychometric instruments to measure the influence of behavioral traits on patients' satisfaction after multifocal IOL surgery. A study of a LASIK patient population using a personality instrument found that patients with higher preoperative levels of depressive symptoms were less satisfied with visual quality postoperatively compared to patients with low levels of depressive symptoms.² Several studies in other specialties suggest an association between depression and decreased postoperative satisfaction^3-5 and aesthetic outcome.⁵ Individuals with depression and anxiety are more likely to express dissatisfaction over unmet expectations.⁶ As with any surgical or medical consultation, it is useful to question patients as to the presence or history of psychiatric disorders and whether they have received or are receiving treatment for that condition. Always ask a patient taking psychotropic medications why the drugs were prescribed, because many are commonly used for nonpsychiatric indications. Obtaining such information allows you to determine whether clearance is needed from the prescribing physician prior to scheduling surgery. Rather than automatically contraindicating surgery, such information can be used to improve patient counseling and the timing of surgery if the patient is otherwise a suitable candidate for multifocal IOLs. With regard to personality traits, pessimism and neuroticism have been associated with lower satisfaction ratings after surgery.^7,8 Life satisfaction, dispositional optimism, and coping styles have also been reported to influence surgical outcomes.^9-11 Assessing a surgical candidate's preferred coping styles and whether the person has successfully dealt with prior stressors is also helpful in determining who should undergo surgery.

CONCLUSION
Emotions play an important role in the overall experience of patients receiving multifocal IOLs. Surgeons should inquire about psychosocial factors as part of the selection of suitable candidates, and such information can also be used to customize preoperative and postoperative counseling to maximize patients' satisfaction. Establishing and maintaining a genuine, positive emotional connection with patients from the moment they enter the clinic and throughout the surgical experience will improve their acceptance of multifocal IOLs.

I look forward to discussing these and other issues in a new column to be published in Cataract & Refractive Surgery Today. I hope readers will share questions or issues with me that they would like to see addressed in the future.

Jennifer S. Morse, MD, is in private practice as a consultant for medical and surgical psychiatry in San Diego, California. Dr. Morse may be reached at (610) 405-5919; jmorsemd@aol.com.

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