Viewpoint FROM THE CHIEF MEDICAL EDITOR

Paul S. Koch M.D.

Stubborn Surgeon = Unhappy Patient

Last week I saw a sad woman in my office. She was from out of town, visiting Providence on business, and a mutual friend hooked us up. She wanted to see me because she wasn’t happy with her multifocal implants.

I told her that while most patients are very happy with their multifocals, my experience mirrored the FDA clinical trials, which showed a small percentage of patients developing severe glare and vision disturbances. Unfortunately, we still don’t know how to predict in advance which patients will and which won’t have problems.

She then shared the rest of her story. When she told her surgeon she was having problems, he insisted these would resolve after she had her other eye done. When both eyes bothered her, he insisted that she would eventually get used to it, and so she waited. By the time I saw her, she had waited more than a year.

As time went by and nothing improved, she begged to have the implants removed. Her surgeon insisted that would not be necessary and he confidently declared that he had never had to remove a multifocal lens She couldn’t understand why she was the only one who couldn’t adjust. Eventually things got so bad for her that she ended up taking antidepressants.

She asked me why he wouldn’t take them out. I didn’t have an answer.

No Lens Is Perfect

Removing a lens that doesn’t work for a patient is not an admission of failure or defeat. We routinely exchange monofocal lenses for a wide variety of indications and never feel bad about it. Why do we have a resistance to removing multifocal lenses when we don’t hesitate for monofocals?

Some fear that removing a multifocal unfairly criticizes the lens or the surgeon’s selection. That’s simply not true. We know most patients adjust to multifocals easily, but others cannot. Just because many do, it doesn’t follow that everyone must.

Refusing to remove a multifocal lens could reflect the surgeon’s ego, or maybe it’s optimism, but the reality is that these lenses do not have a special exemption. Every kind of IOL ever invented has needed to be taken out occasionally. That’s just a fact.

Almost 30 years ago I took Charlie Kelman’s course on his tripodal anterior chamber intraocular lens. Someone asked him if his implant would ever have to be removed. “Absolutely,” he said. “I didn’t design a lens that would never have to come out.” And then he smiled. “Neither did God.”