Prof. Burkhard Dick

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Sometimes, a little background music helps one to come to grips with one’s feelings. Whilst I was thinking of a particular patient one day, the juke box in my brain started playing Cher’s 1980s hit ‘If I could turn back time’.

If I had been able to turn the clock back just a couple of weeks earlier, I would have recommended to the 50-something year-old patient, after the initial examination, to go somewhere else, maybe to one of the (very) few colleagues I am not on the best terms with and have that surgeon implant those trifocal IOLs. But time travel being a dream, I undertook the procedure myself and was now facing the consequences.

His vision was 20/20, the IOL could not have been better positioned and there was, two days after the operation of the second eye, not the slightest hint of inflammation. But the patient was, as I now learned, a born complainer – the slight haze really bothered him and the intermediate vision was not as he had hoped it would be. I told myself that a person with such a mentality would probably have been better served with monofocal IOLs (mIOLs). But of course, it was too late.

At least I could counter his complaining over the money he had spent. I showed him the newspaper I had kept, reporting that the United States FDA had approved a gene therapy for the treatment of relatively rare inherited disease – the effects being that the patients were, in some cases, able to put away their navigational canes and recognise the faces of loved ones again.

The price tag was a whopping $850,000 for a one-time treatment. It at least allayed the financial aspect of his discontent.

Reversing the result of an operation has, over the long course of medical history, mostly been tainted by the feeling of failure on the part of the physician. However, in 21st century ophthalmology, with a large segment of the population more demanding than ever before (particularly those interested in refractive surgery), doing some revision or re-adjustment of an earlier intervention is no longer-fortunately-an admission that something went wrong.

It is, rather, a tribute to the sometimes overly high expectations we have to meet – when, for instance, a three-quarter diopter beyond the target refraction is a serious problem, or the challenges of a mIOL turn out to be greater than anticipated. Therefore, it is another milestone in the already breath-taking development of current ophthalmology when postoperative corrections and adjustments become part of our service portfolio.

A couple of years ago, we began implanting light-adjustable IOLs and had satisfying results in patients who were a bit off the desired refractive status. Now, our hopes rest on a new concept, in large part due to the endeavours of Professor Josef Bille and his admirable sense of innovation: refractive index shaping (RIS); if it works in clinical practice as it has so far in experiments, it will not only enable the surgeon to add or distract from the refractive power of an implanted IOL, but also change a multifocal optic into a monofocal, if need be – and back again, if the complaining never stops.

Such readjustments have the potential to satisfy even the most critical patient, maybe even my complainer-in-chief. And the fitting tune to celebrate this development when facing a discontented patient might be Guns N’ Roses’ ‘November Rain’: 

Nothin’ lasts forever, and we both know hearts can change...

Prof. Dick is director and chairman at the University Eye Hospital, Bochum, Germany. Prof. Dick is a member of the 

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