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Up Front: Chief Medical Editor's Page | Mar 2017

Lines Lost

The chain of events leading toward refractive or cataract surgery begins with a complaint. It may be the loss of an ability such as reading up close or driving at night, or it may be the culmination of years of frustration originating in childhood. Human nature is such that many complaints exist simultaneously. To make sense of them all, we physicians insist that one of the complaints be designated “chief.”

Over the course of several decades, McKinley Morganfield, better known as Muddy Waters, recorded dozens of blues songs touching upon the familiar subjects of frustrated love, financial hardship, temptation, jealousy, and loneliness. He vocalized many problems, but if I had to identify his “chief complaint,” it would be loss. Whether it was the loss of a woman, a job, a home, money, or his dignity, Waters mightily felt the blues. Loss is a universal feature of the human condition, and regardless of what someone has, eventually he or she loses everything. In the song “You Can’t Lose What You Never Had,” Waters describes the sadness he feels over the loss of a woman, but he reflects that his sadness is only possible because of his prior love for her.

One of the most famous works of the well-known Victorian poet Alfred, Lord Tennyson, is “In Memoriam A.H.H.” It contains the verse, “’Tis better to have loved and lost / Than never to have loved at all.” Tennyson wrote the poem to commemorate his feelings of friendship for his fellow poet Arthur Hallam, who died of a stroke at age 22.1 Like Waters, Tennyson seems to be saying that, by definition, the loss of anything can only follow the possession thereof.

Let’s consider two refractive surgery patients. The first has been myopic since childhood and finally presents for LASIK in her late 20s. She has never really possessed sharp UCVA and thus has not lost it. Her frustration over her condition is real enough, but although refractive surgery can offer phenomenal results, only a very small percentage of patients like her will undergo it. The overwhelming majority of them will opt instead for spectacles or contact lenses. Now, let’s consider the second patient, a presbyopic hyperope, who previously had superb vision at all distances. He has lost all uncorrected near ability and is in the process of losing distance function as well. This patient has the blues. When questioned, he waxes nostalgic about the days when his vision was amazing. If we mix in a bit of cataract with the attendant loss of visual quality, he will be extremely highly motivated to fix the problem. In my experience, this category of patient opts for some form of refractive surgery at a far higher rate than does the younger myopic population.

Although this willingness to undergo surgery is certainly dependent upon economic forces, I believe that we are witnessing a shift in how our patients think about presbyopia. Owing to the tremendous technological advances in presbyopic correction coupled with patients’ sense of losing a treasured ability, the adoption rate of this form of surgery is set to increase dramatically. For our cataract patients, the first major shift in thinking occurred years ago when we began to strive for good uncorrected distance vision as our typical goal. Now, it is increasingly common for patients to desire and achieve good uncorrected function for near vision as well. Our mission should be to restore as much of what they have loved and lost as we can.

Steven J. Dell, MD Chief Medical Editor

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