August 06, 2012
4 min read

Managing the dissatisfied premium IOL patient

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

We were unable to process your request. Please try again later. If you continue to have this issue please contact

Various studies show that up to 25% of patients will be unhappy in some way, indicating so by either complaining outright or just leaving the practice and seeking a second opinion. The old adage still holds true: A happy patient will refer one or fewer patients, but an unhappy patient will tell 10 or more to avoid you.

As I have revealed in the first seven parts of this series, patient satisfaction will require due diligence on the part of the surgeon in terms of setting realistic expectations, performing the proper preoperative evaluation, managing the ocular surface, managing astigmatism, preventing cystoid macular edema, managing posterior capsular opacification, and selecting the correct IOL and IOL power for your patient.

In my experience, there are three types of dissatisfied patient when it comes to premium IOL technology: the post-refractive surgery idealist, the surprised multi-pathology patient and the timid-by-proxy patient.

Post-refractive surgery patients

Typically, the post-refractive surgery patient will have the highest expectations after cataract surgery, whether receiving a monofocal or premium IOL. Most of these patients expect the best and will most likely choose a premium IOL at the time of cataract surgery.

Mitchell A. Jackson, MD 

Mitchell A. Jackson

Hitting the postoperative refractive target is usually most difficult in RK patients. Even if the target is achieved, these patients typically have the “trampoline” effect of vision fluctuation and the “starburst” effect from the RK scars. RK patients normally are loaded with wavefront aberrations from the outset, and avoiding multifocal IOLs in this subset of post-refractive surgery patients is probably the safest route.

With regard to LASIK patients, data was presented by me at the joint meeting of OSN, the Italian Society of Ophthalmology and the Italian Association of Cataract and Refractive Surgery in Milan, Italy, in May, looking at angle kappa as the determining factor for which post-LASIK patients should receive a multifocal IOL. The conclusions from this presentation suggested that patients with an angle kappa (as measured with a Marco OPD-Scan III or Hoya iTrace device) greater than 0.40 mm would be happier with an appropriate aspheric monofocal or accommodating IOL, and multifocal IOLs would be equally successful in patients with an angle kappa of less than 0.40 mm. If the surgeon has access to an intraoperative aberrometry device, this method appears to be the most effective in IOL confirmation in post-LASIK and post-RK patients.

Maintaining the ocular surface, treating astigmatism and selecting the correct IOL power are of utmost importance in post-refractive surgery patients as a general rule, and I have addressed these three items previously in this series. Most importantly, setting expectations is really the key in the post-refractive surgery patient. For example, not only should you not promise the ability to perform near vision tasks without glasses if a toric IOL is placed unless monovision is planned, but you should actually tell the patient they will need reading glasses for all near vision tasks in this setting.

Surprised multi-pathology patients

The surprised multi-pathology patient is nearly detrimental in the premium IOL setting. Not checking for macular pathology preoperatively by optical coherence tomography and/or a thorough dilated retinal evaluation can lead to the occasional and usually non-treatable dissatisfied outcome.

Epiretinal membranes are probably the most notorious culprit in this category and can be missed on routine retinal evaluation without the aid of OCT technology. Patients with age-related macular degeneration even in the mild dry form can also show displeasure postoperatively due to spending lots of money on a premium IOL and expecting that it will simultaneously treat the AMD.

It is amazing how many patients, even after detailed preoperative counseling, believe that IOL surgery will correct the macular pathology. I truly find this category of patients to be the most time-consuming in terms of chair time. One way to minimize this problem is to make sure a family member is present at the time of counseling for cataract surgery so it is fully understood what visual outcome can and/or cannot be achieved postoperatively.

Timid-by-proxy patients

I call the last category the timid-by-proxy patient. Unfortunately, I fell into this trap once and hopefully never will again.

I had a modern-day multifocal IOL technology patient with postoperatively uncorrected vision of 20/15 at distance, intermediate and near, with each eye and with both eyes together; plano refraction; no posterior capsule opacification; normal OCT; and minimal wavefront aberrations with essentially no complaints.

The only complainer was the patient’s spouse, who insisted the IOLs be removed due to her husband being a “prisoner at night.” The patient stated he could drive at night with minimal halo effect, but his spouse was very controlling and demanding.

I decided to cave in and do an IOL exchange, which left the patient requiring glasses to achieve the same type of visual outcome. Instead of his spouse complaining, I now have the actual patient complaining about glasses.

My lesson here is to avoid the by-proxy complainer and only heed the real complaint(s) of the actual patient.

Pearls for handling dissatisfied patients

In dealing with the dissatisfied patient, I offer some tips to minimize your agony as a premium IOL surgeon.

  • Be prepared before entering the room. Make sure refraction, OCT and corneal topography have all been performed before the patient encounter so you can formulate a solution for the problem at hand.
  • Address the complaint immediately upon entering the room. Most patients are ready to be in offensive mode, which can be diffused by the surgeon understanding and being empathetic regarding the patient’s complaint and confirming that the diagnostic tests performed helped the surgeon understand it even better.
  • Formulate a list of solutions for the patient’s problem. For example, if it is residual astigmatism in a multifocal IOL, let the patient know that limbal relaxing incisions and/or laser vision correction are options available once the eye has stabilized after the initial surgical healing period.
  • When the patient-surgeon relationship has reached a stalling point, do not hesitate to recommend a referral to a colleague with similar expertise (a cataract surgeon who actually employs and has experience with premium IOL technology) and continue to follow up with the patient in an effort to restore the confidence lost.

My final words of encouragement in the context of a dissatisfied patient are to always stay calm, listen to the patient to find out the real objective complaint (the moment they spend money there is already an inherent complaint), validate the complaint, accept responsibility as the surgeon, provide real solutions and hopefully in the end the premium IOL surgery will truly be a premium experience.

Stay tuned for the ninth part of this 10-part series: managing costs in a private practice setting as it relates to premium IOL surgery.

  • Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Avenue, Suite L, Lake Villa, IL 60046; 847-356-0700; fax: 847-589-0609; email:
  • Disclosure: Jackson is a consultant for Hoya and is on the speakers bureau for AMO, Bausch + Lomb and Marco Technologies.