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Cover Stories | March 2021

Re-Evaluating Informed Consent In a Modern Practice

It’s more about personalized education than about technology.

Informed consent is one of the most important aspects of practicing medicine. It is the procedure through which patients knowingly place themselves in a doctor’s care. Too often, informed consent is reduced to referencing a signed document on a preoperative checklist. How should this process be viewed in a modern medical practice?

Some may associate modernizing informed consent with replacing traditional paper forms and oral discussion with electronic signatures, smart tablets, and educational videos. This misses the most important point of modern informed consent. As ethicists and lawyers alike say, informed consent is a process. A majority of that process involves educating and informing patients. How should we cataract surgeons modernize patient education? It is less about substituting technology for paper and more about reconsidering our patients’ thought processes, lifestyle needs, and opportunity costs.


A common refrain at conferences where attorneys are invited to share their wisdom with us is that all patient-facing content is part of the informed consent process. Specifically, marketing materials and website content must be accurate and realistic. There’s a difference between discussing a goal and a promised result, and there should not be a mismatch between the marketing materials for a procedure and the informed consent document.

I am not recommending negativity in marketing. The wonderful reality of our field is that the majority of our patients achieve significantly better vision, more visual freedom, and an improved quality of life after surgery. Overpromising results, however, starts the educational process on the wrong note.

Underpersonalization is another pitfall to avoid when educating patients. All patients are not alike. Certain characteristics increase the risk of complications, and others reduce the likelihood of achieving a predictable, crisp visual result. These characteristics must be carefully identified and discussed with patients preoperatively. For example, educating patients about the risks presented by floppy irises, high myopia, dense cataracts, and weak zonules helps to set realistic expectations for patients with those conditions. We must also hold a grounded discussion of how epithelial basement membrane dystrophy, dry eye disease, and a history of refractive surgery can affect outcomes and postoperative wound healing and visual recovery.


Modern refractive cataract surgery requires assessing patients’ hobbies and lifestyle needs. Humanity is well into its second decade of frequent handheld device use. Screens are ubiquitous. Many devices have a screen time feature that displays average hourly usage per day, and it can be sobering to view these statistics. Although we may take for granted that mobile device use fits into the near vision category, patients’ phone use in particular should be addressed at some point in the educational process.

The informed consent process should cover the varying ability of new technologies to meet these needs. For example, I find competitive target shooters and hunters to be some of my most demanding patients. They simultaneously require crisp distance visual acuity to view targets and precise near and intermediate visual acuity for iron sights in the same dominant eye. My team and I discuss with them and document which portions of their visual goals are realistically achievable. We have been successful with currently available IOLs because we hold realistic discussions with patients about their personalized visual needs.


The latest IOLs and refractive options are more customizable than earlier iterations. A major part of the informed consent process is discussing available vision or lens options while emphasizing the personalized benefits of the single, final chosen plan. Not to disclose the other options would be unfair to patients, but simply presenting a comprehensive menu of options without reassuring patients about the final decision could result in choice paralysis and reduce patient satisfaction.1,2

The informed consent process is modernized not by getting an electronic signature but by considering how best to educate patients.

1. Iyengar SS, Lepper MR. When choice is demotivating: can one desire too much of a good thing? J Pers Soc Psychol. 2000;79(6):995-1006.

2. Scheibehenne B, Greifeneder R, Todd PM. Can there ever be too many options? A meta-analytic review of choice overload. J Consumer Res. 2010;37(3):409-425.

O. Bennett Walton, MD, MBA
  • Slade & Baker Vision, Houston
  • Member, CRST Editorial Advisory Board
  • drwalton@visiontexas.com
  • Financial disclosure: None
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