Eyeworld

WINTER 2026 | EYEWORLD | 61 R Relevant disclosures Donaldson: AbbVie, Alcon, Bausch + Lomb, BioTissue, BVI, Dompé, Glaukos, Harrow, Healio AI, iOR, Johnson & Johnson Vision, LENSAR, Lumenis, Rayner, ScienceBased Health, Sun Pharma, Tarsus, Théa Pharma, Versea, Zeiss Majmudar: Alcon, Bausch + Lomb, Dompé, Glaukos, Sun Pharma Wiley: Alcon, Bausch + Lomb, BVI, Johnson & Johnson Vision, Rayner, Zeiss Contact Donaldson: KDonaldson@med.miami.edu Majmudar: pamajmudar@yahoo.com Wiley: wwiley@midwestvision.com of the hardest scenarios because there's often nothing to "fix." He approaches these patients first with validation. "I start by acknowledging their experience is real to them, even if I can't find a correctable cause." He then reexamines them, just in case repeat refraction topography, OCT, dry eye workup, etc., reveals something subtle. "Even when it doesn't, the patient needs to see that you took the complaint seriously rather than assuming it was in their head." From there, he'll explain the possibility that the patient still needs time to neuroadapt, and he'll treat what he can, setting a timeline for management, often with a closer than usual follow-up, so patients don't feel dismissed. He said that sometimes referring is helpful as well. "A second opinion from a trusted colleague can sometimes do more for the patient's peace of mind than anything I say myself—it's not a fail- ure; it's often the fastest path to resolution." Dr. Donaldson also makes sure to validate the patient's experience. She explains what she has evaluated, reviews reassuring findings with the patient, and tries to define what the patient might still be struggling with. "Most important- ly, I do not dismiss the concern simply because the examination looks good. These patients need to know that they have been heard, that their symptoms are real, and that we will continue working with them—even if the safest decision is not to perform another procedure," she said. Getting ahead of the problem All surgeons want their patients to be happy with their refractive surgery experience—be it corneal refractive or cataract—and outcome from the outset. There are a few things ophthal- mologists can watch out for and address in the preop stage to help achieve a positive outcome. One is keeping an eye on ocular comor- bidities that aren't "wrong" but that will affect outcomes. Dr. Majmudar listed these as mild dry eye, epiretinal membrane, early macular chang- es, irregular astigmatism, and angle kappa/an- gle alpha issues that make premium IOLs riskier. "These patients may measure fine on the day of surgery but be more prone to fluctuating or suboptimal quality of vision afterward," he said. "None of these are absolute contraindications, but they all change how I counsel, what I doc- ument, and sometimes which lens technology I choose (or avoid)." Then there are the patients whose expecta- tions don't match what their eye can realistically deliver. These include patients who "bring in a list of exact specifications, who've researched extensively online, and arrive with rigid de- mands, or who seem to be seeking perfection rather than improvement," Dr. Majmudar said. It also includes those whose visual de- mands exceed what current technology can deliver, such as those who require crisp vision in low-contrast conditions, and those with psy- chological or social red flags. The latter, in Dr. Majmudar's book, includes those with "a history of dissatisfaction with other medical or cosmetic procedures, active litigation involving a prior provider, unstable mood or anxiety disorders that are poorly controlled, or unrealistic time pressure." Dr. Majmudar's number one pearl to ensure a patient is happy with their outcome is to focus on preoperative counseling. "The unhappy patient is created preoperatively, not postop- eratively," he said. This equates to real time spent explaining what "good vision" looks like, explicitly discussing specific tradeoffs between the technology being considered. "Patients forgive an outcome they were warned about far more easily than one that surprises them. I'd rather underpromise and have a patient thrilled at 20/25 than overpromise and have a patient miserable at 20/20." Dr. Donaldson said her number one pearl is also to align expectations preop. "During the preoperative discussion, we need to use words such as 'compromise,' 'no perfect lens,' and 'glare and halos.' Preoperative patient education makes the patient a partner in this process and also helps the patient share the responsibility of the outcome." She said it's important for the patient to understand that cataract surgery is a process that involves two eyes and a period of neuroadaptation. "The happiest patient is not necessarily the patient with the most advanced technology or the best Snellen acuity; it is the patient whose postoperative experience matches what they were prepared to expect," she said, and this requires careful patient selection, ocular surface optimization, and an honest discussion about visual tradeoffs with certain lenses. As Dr. Wiley put it, "identifying that mis- match before surgery is far better than manag- ing it after. The goal is not becoming skilled at rescuing unhappy patients. It is getting good enough at reading them beforehand that rescue rarely becomes necessary."

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