Underpromise and overdeliver is the mantra of ophthalmologists who offer premium IOLs. Why, then, does adoption remain limited? Negative patient narratives on social media and, at times, in professional publications1 can undermine trust in individual clinics and the industry as a whole.
According to data published by Francesco Carones, MD, and colleagues in 2014,2 approximately 30% to 60% of patients globally are interested in receiving a premium IOL, but only 10% to 20% of surgeons offer these products. In 9,000 unique online responses from patients around the globe, 61% of them expressed interest in reducing their spectacle dependence after cataract surgery. Responses were collected via a modified version of the questionnaire developed by Steven J. Dell, MD, embedded on the IOL-adviser.com website (www.iol-adviser.com/iol-questionaire). Only each user’s first submission was analyzed (spectacle freedom, visual needs, tolerance to positive dysphotopsia, glasses use). Results were presented at the Ophthalpreneurs 2024 conference.3 The data represent patients who were searching for information about IOLs on the internet, YouTube, and Google to understand the options better.
Based on 6 years of conversations with patients and social media analysis, I have found a gap between what eye care providers communicate to patients and what these individuals expect. This article examines the problem and strategies to resolve it.
MISALIGNED GOALS
The value proposition of premium IOLs is that they can provide an increased quality and/or range of vision. A key issue is that eye care providers and patients define good vision differently. Clinicians typically mean 20/20 uncorrected distance visual acuity and an increased range of vision without a meaningful loss of contrast sensitivity. Patients, however, often define good vision as the best visual experience of their lives or vision that allows them to enjoy the activities they value the most with the least discomfort and inconvenience. This disconnect is often why patients are dissatisfied with objectively excellent surgical outcomes.
IMPROVING UNDERSTANDING AND COMMUNICATION
Achieving a high rate of patient satisfaction after refractive cataract surgery with premium IOL technology requires understanding patients’ lifestyles and visual goals. I developed the Smart Sight Framework to structure preoperative conversations and improve patient communication. The Smart Sight Framework is a four-phase consultation model: phases 1 and 2 surface the patient’s core values and priorities, phase 3 links those values to clinical options and trade-offs, and phase 4 supports a shared final decision. Rather than start a basic, one-size-fits-all education flow—commonly used in the industry with standard videos, brochures, and articles—the conversation should be individualized from the outset.
Case Example No. 1
An emmetropic 57-year-old woman presented for a cataract surgery evaluation. The preoperative consultation included a discussion of the patient’s visual needs that revealed she prioritized crisp far visual acuity, wished to preserve her contrast sensitivity, and desired but did not require clear uncorrected near visual acuity postoperatively. Surgical strategies discussed with her included monovision with a monofocal IOL, mini-monovision with an extended depth of focus IOL, and trifocal IOLs. The patient was at a loss as to which option to choose.
The problem, I determined, was that no one had asked her about her lifestyle or visual needs. A discussion with her using the Smart Sight Framework revealed that she enjoys viewing architecture, night city, and engaging in nature hikes that take her to scenic locations. Top priority was night walks in the city, emotionally the most enjoyable, as well as nature and scenery. A trifocal would likely have been frustrating for her priorities. A mini-monovision approach using an enhanced monofocal IOL was used after her values were clarified during the final consultation. This case reminded me how even the most detailed consultations can miss the mark when values are not recognized.
Case Example No. 2
A mildly myopic patient underwent a refractive lens exchange in each eye with a presbyopia-correcting IOL. Preoperatively, she completed a vision simulation and was deemed an ideal candidate for the lens technology selected. Although her UCVA was 20/20 OU and her range of vision had increased after surgery, she was extremely unhappy with her postoperative vision, which she detailed on Reddit.
During our postoperative discussion, I applied the Smart Sight Framework to understand the cause of her dissatisfaction. The discussion revealed concerns about distance clarity and dim-light performance that had not been fully addressed preoperatively. Her values centered on maintaining high visual standards with no compromises; she would have accepted wearing glasses as a trade-off but not a reduction in perceived clarity. The preoperative discussion had not gone deeper than general information and simplistic marketing language. A few weeks after surgery, the patient underwent an IOL exchange in each eye for a monofocal lens, which ultimately brought her peace of mind.
Case Example No. 3
A man with limited financial means underwent cataract surgery with a monofocal IOL in each eye. His uncorrected distance visual acuity after surgery was 20/16 OU.
The patient was frustrated with his postoperative vision. He found a video on YouTube emphasizing that his need for reading glasses after surgery was normal. A subsequent discussion with him using the Smart Sight Framework revealed that his profession as a decorator requires crisp vision at 80 to 150 cm. The patient was then educated on monofocal plus and extended depth of focus IOLs and ultimately decided to undergo an IOL exchange for a premium extended depth of focus lens in each eye.
CONCLUSION
Clinically logical algorithms and the underpromise-and-overdeliver approach work well for a large number of patients. More reliable success, however, requires improved communication and a deep preoperative understanding of patients’ lifestyles and visual goals. Use of the Smart Sight Framework can help deliver higher patient satisfaction with greater consistency. For most patients, vision is not just a clinical metric but also a lived, emotional experience, and that is where the conversation must begin.
1. Panagiotopoulou EK, Ntonti P, Vlachou E, Georgantzoglou K, Labiris G. Patients’ expectations in lens extraction surgery: a systematic review. Acta Med (Hradec Kralove). 2018;61(4):115-124.
2. Carones F, Knorz MC, Jackson D, Samiian A. Influence of co-payment levels on patient and surgeon acceptance of advanced technology intraocular lenses. J Refract Surg. 2014;30(4):278-281.
3. Sologub O. The missing part of the equation on how to engage the patients to the eye surgery is … the patient. Presented at: Ophthalpreneurs 2024 Conference; March 2024; Stresa, Milano, Italy.
