Eyeworld

58 | EYEWORLD | WINTER 2026 R EFRACTIVE TO THE MOON AND BACK by Liz Hillman Editorial Co-Director About the physicians Kendall Donaldson, MD, MS Medical Director Bascom Palmer Eye Institute at Plantation Plantation, Florida Parag Majmudar, MD Professor of Ophthalmology Rush Medical College CEO Chicago Cornea Consultants Chicago, Illinois William Wiley, MD Medical Director Cleveland Eye Clinic Division of Midwest Vision Partners Cleveland, Ohio nucleus), cystoid macular edema, and some- times no identifiable cause. Identifying what's at play begins with listen- ing. "It is very important, first and foremost, to listen to the patient," Dr. Majmudar said. "This is followed by a thorough systematic examina- tion that addresses each of these issues—refrac- tion, topography, OCT, aberrometry, careful slit lamp evaluation. It may be a process of elimina- tion to rule out each of these areas." Dr. Donaldson begins her unhappy patient consultations by thoroughly listening to the details of their complaint and performing a slit lamp exam. "I begin by asking the patient to describe the problem in functional terms: Is the vision blurred, fluctuating, distorted, doubled, or associated with glare or halos? Is it worse at distance, intermediate, or near? Does it vary with blinking, lighting, time of day, or between the two eyes? I also revisit what the patient expected before surgery. Many times, patients just want to be heard and reassured that their concern is normal and/or common and will improve over time," she said. Dr. Donaldson's physical evaluation is sys- tematic and includes the following: • Uncorrected and best-corrected vision at rele- vant distances • Manifest refraction, including whether the patient appreciates the correction • Slit lamp examination with careful assess- ment of the tear film and ocular surface • Corneal topography or tomography (including undilated ray tracing images) • Biometry • Epithelial mapping and aberrometry when indicated • Evaluation of IOL centration, tilt, and effec- tive lens position (with slit lamp examination or rarely with high resolution ultrasound) • Assessment for posterior capsular opacification • Macular OCT and evaluation of the optic nerve and retina • Assessment of binocular vision and ocular dominance when relevant • Review of old records and/or discussion with the primary surgeon (when seeking consulta- tion) "Most of the unhappy patients I see are not actually optical problems—they are expecta- tion problems," Dr. Wiley said. Unfortunately, in these situations, by the time the patient is W hether it's corneal refractive sur- gery, refractive cataract surgery with a premium IOL, or standard cataract surgery with a mono- focal IOL, patients expect their outcome to be nothing short of perfect—20/20, halo-free, shoot for the stars. But every surgeon eventually meets the patient who isn't over the moon with their outcome. When the outcome falls short of patient expectations, the surgeon has a duty to help them find their way back to a positive result. "Fortunately, truly unhappy patients are un- common, but we routinely see patients who re- quire additional reassurance, treatment, or time to achieve satisfaction after cataract surgery," said Kendall Donaldson, MD, MS. "After corneal refractive surgery, common concerns include fluctuating vision, dry eye symptoms, under- or overcorrection, regression, and reduced quality of vision, particularly at night. After refractive cataract surgery, dissatisfaction may also result from astigmatism, posterior capsular opacifica- tion, macular or corneal pathology, inadequate near vision, reduced contrast sensitivity, or halos and glare associated with presbyopia-correcting IOLs." Depending on the situation, there are sever- al courses of action that can help bring a patient to 20/happy, ranging from conservative coun- seling to more aggressive approaches like IOL exchange. Dr. Donaldson, Parag Majmudar, MD, and William Wiley, MD, provided their perspec- tives on the most common reasons for patient complaints postop and how to mitigate them. "If one performs enough surgery, one will encounter their fair share of unhappy patients," Dr. Majmudar said. "This applies to all surgeons, with all surgeries and lens choices—even a patient who opts for a standard monofocal IOL. There are many potential reasons for dissatisfac- tion. Some can be identified preoperatively and avoided; others may not be." Identifying the cause Dr. Majmudar listed several possible causes for postop patient dissatisfaction: unrealistic expec- tations, residual refractive error, ocular surface issues, corneal irregularity (EBMD, pterygium, Salzmann's nodules), retinal issues, dysphotop- sia, intraoperative complications (decentered ablation, posterior capsular rupture, dropped When the stars don't align: managing the unhappy patient

• Cover