In my youth, I was mesmerized by the reruns of the television show The Six Million Dollar Man. Steve Austin, the lead character in the show, was a cyborg of sorts, with a bionic eye giving him superhuman vision including 20x zoom and infrared capabilities. It’s fair to say this was the beginning of my interest in ophthalmology.
Later in life I realized that the technology for a bionic eye does not yet exist. Yes, we can restore good or even great vision to many patients, but surgery still cannot restore perfect vision of youth, let along result in superhuman visual capabilities. This is something that we need to relay to our patients.
Imagine a 35-year-old patient who sees you for a recent injury that has caused a mild traumatic cataract in one eye. The unaffected eye sees 20/20 and is completely healthy. The other eye has a mild area of early cataract development and the acuity has been reduced to 20/25. The patient notices this slight decrease in vision and desires surgery because he wants to regain the perfect vision he once had in that eye. How do you counsel the patient?
There are currently no man-made body parts as good as their young, healthy, human counterparts. There’s no artificial hip implant, cardiac valve, or intraocular lens that will restore function to the level of the corresponding youthful body part. Our current lens implants can provide excellent vision at a fixed distance, but they struggle to give the wide range of vision that a youthful crystalline lens provides. Our current generation of multifocal, extended depth of field, and pseudo-accommodating lens implants are quite good but not sufficient enough to give truly perfect vision.
It’s our job as ophthalmologists to inform these patients about the limitations of our current technology. Making a 35-year-old patient pseudophakic will cause an immediate loss of accommodation and a collapse of the range of vision without glasses. A young patient is used to having excellent accommodation and living without that is difficult to imagine.
Satisfaction with surgery is the difference between the patient’s expectations and the results of surgery. We should aim to increase this delta by striving to give the best surgery possible, but also by tempering the patient’s expectations.
The reason why senior patients are thrilled with the results of cataract surgery is partially because of their reasonable expectations. Our 75-year-old patients generally do not expect to see like a 35-year-old patient. If we can restore excellent distance vision to 75-year-old patients and then have them use reading glasses for near work, they will be very happy. If we address their presbyopia with one of our current technologies, they may be even happier.
The problem with a 35-year-old patient is that he or she expects to see like a perfectly healthy 35-year-old. I completely understand, but I also know the limitations of our current ophthalmic technologies. I need to explain to this patient that, while the desire is understandable, we will not be able to fulfill them. I would advise this hypothetical patient to avoid surgery for now. Live with the mild unilateral cataract, which could take many years to progress, and let the pipeline of new ophthalmic technologies deliver a better product in the future.
One day we will have truly accommodating lens implants and the ability to deliver exacting refractive outcomes for essentially every patient. I don’t know if we will ever get to the level of the bionic eye that I enjoyed watching on television in my youth, but if you can give me 3 or 4 diopters of true accommodation, I will happily settle for that.