“There’s no perfect or right lens for every patient, however. The surgeon must work with the patient to decide which lens is best for their needs and lifestyle.” [1]
Dr. David Yan, Ophthalmologist-in-Chief for Sinai Health, 2022
It’s just a matter of time. Despite your healthy lifestyle, it’s quite likely that you’ll be in the situation I’m now facing. My vision is getting cloudy.
It began with a routine annual eye examination when my optometrist noted that the prescription for my right eye had changed rather dramatically over the previous 11 months (by -.75 diopters, for those who understand their vision Rx). The lens in each eye — that part of the eye that focuses to make images close or distant sharper — is becoming cloudy. These cloudy lenses, called cataracts, are beginning to negatively impact my vision, especially at night and in my right eye. I still see quite well, for now, but that will change. My optometrist referred me a prominent ophthalmologist-surgeon in downtown Toronto who has two private practice locations, in addition to his hospital responsibilities.
Since accepting that I needed cataract surgery, after my first and only meeting with this ophthalmologist, I wanted to feel confident about two issues: the person who would be performing the cataract surgery, and which intraocular lens (IOL) would be surgically implanted in my eyes to replace my cloudy lens. I’ve been wearing corrective lenses since before the age of two. Entertaining the idea of having the lens in my eyes removed and replaced by a “hydrophobic acrylic biomaterial” was accompanied by some apprehension.
I had that brief meeting with the ophthalmologist-surgeon on November 28, 2023, after various eye tests that same morning, when he confirmed that I had cataracts. Surgery, in his words, was a “no-brainer.” I did not then or ever have a discussion with the ophthalmologist about intraocular lenses (IOL) or which specific IOL would best meet my needs, lifestyle, and visual challenges (e.g., myopia, astigmatism, and now cataracts). I never met or spoke with or saw the ophthalmologist-surgeon after this first meeting.
A month later, on December 28, 2023, my wife and I met with the ophthalmologist’s surgical coordinator, who conducted biometric measurements of my eyes and introduced my wife and I to the IOL options. After performing the measurements associated with biometric testing and astigmatism management, the surgical coordinator presented us various categories of lenses, from the OHIP-covered option to the specialty premium trifocal IOLs. The OHIP option was presented as a clearly inferior choice and the depiction of how well one would see with such an implant was blurry. We were then shown a list of twenty-eight lenses from which I was to select the type and brand of lenses I would have implanted in my eyes.
- I paid $300 for “laser biometry” to measure the length of my eyes and shape of my corneas which would, the document I signed reported, provide “your surgeon more precise information to select your IOL implant”. The ophthalmologist was not involved in any discussion of which IOL implant was suitable for my eyes. How this precise information was used was never explained to me or clear.
- I paid $680 for a package labelled “astigmatism management”, in addition to the laser biometry. Both were deemed necessary if I wanted a specialty IOL (i.e., non-OHIP-covered toric lens). By declining the astigmatism management package, I would be agreeing that “I will likely have a significantly greater astigmatism after my surgery; thereby, increasing my need for prescription glasses for both distance and reading vision.” The ophthalmologist never discussed with me my astigmatism, nor did anyone on his team, and never discussed with me the results of these tests, the management of my astigmatism, or whether my astigmatism would be surgically corrected and, if so, by femtosecond laser or otherwise.
- My contact lens prescription (Rx) was devised to provide monovision, that is, my right eye Rx is for reading and my dominant left eye Rx for distance vision, and it has served me well for the past 20 years or so. The ophthalmologist never discussed my current monovision prescription with me or presented an IOL monovision solution.
I was uncomfortable being asked to select a lens without input from someone who knew my visual limitations, how they impacted my lens options, and which lens might best suit me. When I asked if the ophthalmologist would be joining us in this discussion, I was informed that he would not, but that the ophthalmologist would likely recommend the Alcon Clareon PanOptix trifocal lens.
After much discussion with my wife and the surgical coordinator, I selected the Alcon Vivaty Toric lens for its good distance and middle vision, lack of halos and glare at night, and for my astigmatism (i.e., Toric lenses correct for astigmatism). I was aware that I would likely need to wear corrective lenses for reading with this choice. Trifocal lenses, the optimal choice for some people, resulted in compromised night vision, I had read, so I rejected that option.
- I was asked to sign a document from the Kensington Eye Institute attesting that I understood I was voluntarily selecting and paying for a specialty IOL and that “the nature of the treatment(s), expected benefits, material side effects, material risks, special or unusual risks, alternative courses of action, as well as the consequences of not having the treatment, have been explained to me by [the ophthalmologist] in a manner that I understand.” While I did voluntarily select the specialty IOL, none of the following items mentioned were explained by or discussed with the ophthalmologist. The ophthalmologist never joined us, participated in the discussion, or offered advice or a recommendation. The ophthalmologist did not, in the words of Dr. Yan at the beginning of this document, “work with the patient to decide which lens is best for their needs and lifestyle.” The ophthalmologist’s signature is also on this document.
After sitting in the waiting room for 10 minutes, the surgical coordinator called me into the office and told me I was not a suitable candidate for the Alcon Vivaty Toric lens because my myopia was too extreme (-8.25 OD and -6.25 OS, according to my August 2023 Rx). This compounded my discomfort as my myopia should have been apparent to anyone who had access to my optometrist’s records, as they did. I told the surgical coordinator that I felt unqualified and uncomfortable in making a lens choice without input from the ophthalmologist, who I believed would know the limitations of my eyes and the advantages and compatibility of lenses on offer. I was informed I wouldn’t be able to meet with the ophthalmologist until well after my surgery date. Meeting with the ophthalmologist would postpone the surgery, I was informed. We agreed I would send the surgical coordinator an email describing my concerns and needs, and he would pass the email on to the ophthalmologist for his feedback.
At home, after hours of Google research, I decided that a monofocal toric lens, which would give me excellent distance vision, was likely the best IOL option for me. On January 2, 2024, I sent my email to the ophthalmologist care of his office email, explaining my needs related to my vision and asking for his recommendations of a lens. I also requested that the ophthalmologist perform the surgery.
On January 3, 2024, his office responded:
“Based on your questions in the email and after looking at your measurements [the ophthalmologist] has picked a Monofocal Toric Lens (Calreon {sic} monofocal) for you.”
The email included a PDF copy of my original email with “monofocal toric” scrawled on it. The surgical coordinator informed me by telephone that the ophthalmologist had read the email and had written his recommendation on it the evening prior. I had no reason at that point not to believe him.
Later that week, I had a telephone call with my optometrist, to solicit his opinion on my IOL choice and to understand if good vision would be possible if I chose a monofocal toric lens and augmented it by corrective lenses for reading. He reassured me this was a tenable solution.
On January 10, 2023, I emailed the ophthalmologist’s office to confirm the date for the first surgery (February 20, 2024), the lens recommended (Alcon Clareon Monofocal Toric), and that the ophthalmologist would be performing the surgery. The following day, January 11, 2024, I received a response from his office:
“Yes, your surgery is booked for February 20, 2024 and it is confirmed. [The ophthalmologist] has picked Alcon’s Clareon monofocal Toric lens for you and I have made a note for [the ophthalmologist], and he will be operating on you.”
The surgery was postponed twice and rescheduled to April 2, 2024, due to emergency surgeries having precedence over elective, I was told. On March 13, 2024, I sent an email to the ophthalmologist’s office expressing that I was looking forward to the surgery and wanted confirmation of the date, that the ophthalmologist would perform the surgery, that the lens to be implanted was the Alcon Clareon Monofocal Toric, and whether there were any other associated costs. On March 18, 2024, his office responded by email:
- “[The ophthalmologist] will be closely working with experienced resident doctors during the surgeries.”
- “The Intraocular lenses are Alcon Clareon Monofocals and based on your measurements [the ophthalmologist] will determine if you need a toric lens or not and we will confirm that with you on a call at least 3 days before your surgery.
I was disappointed and upset to learn the ophthalmologist would not be performing the surgery and, despite prior assurances that he had reviewed my ocular measurements and had recommended the Alcon Clareon Monofocal Toric lens, he apparently had not yet looked at the biometric and astigmatism measurements. It was at this point I lost confidence in the pre-surgical care I was receiving from his office and in the ophthalmologist.
On March 20, 2024, I called the ophthalmologist’s office and spoke to his surgical coordinator. I told him that I’d lost confidence in the surgical process and did not want to proceed with the surgery. He responded that the ophthalmologist had been in the office the day prior and had signed off on the toric lens and in any case, he added, I’d be informed of which lens had been selected 3 days prior to surgery. I was skeptical of his assurances. When I asked for a meeting with the ophthalmologist to address my concerns, he said he would talk to his supervisor and get back to me.
A few days later I received a phone call from my optometrist. He’d been told I had cancelled the surgery and was concerned. I explained my position, which we discussed. We ended the call amicably.
On March 28, 2024, the ophthalmologist’s office called to confirm the surgery date. I informed them that the surgery had been cancelled. They were not aware of this. Shortly after this call, the surgical coordinator called to inform me that the surgery was cancelled and asked if I was going to pay the $500 surgery cancellation fee. I said I would not. I reminded the surgical coordinator that he had promised to get back to me 8 days ago. He responded that my optometrist was to have called me and answered all my questions. I ended the call.
When I resigned myself to the need for cataract surgery, I understood it is routinely performed and safe. I have no doubt that is the case. However, my case was dealt with in such a routine fashion that I felt unsafe. I received perfunctory personal attention, conflicting messaging, and mediocre quality of care. There was no shared doctor-patient decision-making and the accountability for the surgical outcome was spread across three different organizations and several actors, many of whom I would have met for the very first time when they operated on my eyes.
In summary:
- I wanted to be confident in whoever was performing the surgery and asked that the ophthalmologist be the surgeon. I was told the ophthalmologist would be performing the surgery only to be informed later that he would not. I had no confidence in the person who would operate on my eyes because I only knew who would not be operating on my eyes, my ophthalmologist-surgeon.
- I wanted to be confident that the IOL implanted was the best choice for my specific circumstances: my visual challenges and lifestyle. There was never any discussion with the ophthalmologist about which intraocular lenses would best suit my eyes or the advantages and disadvantages of specific lenses, given my visual challenges of myopia, astigmatism, and cataracts. The only discussion of IOL options, with someone who did not know my visual challenges, was frustrating and disappointing.
- On January 3rd I was told “after looking at your measurements the ophthalmologist has picked a Monofocal Toric Lens for you” and two and a half months later (on March 18) was informed “based on your measurements [the ophthalmologist] will determine if you need a toric lens or not.” Both statements can’t be true.
- I paid $680 for “astigmatism management” and $300 for biometric testing but as of March 20 — less than two weeks before the surgery — there was no astigmatism management plan communicated and the ophthalmologist hadn’t yet decided if I even needed toric lenses, much less any corrective astigmatism surgery.
- The ophthalmologist signed a Kensington Clinic document saying he had explained to me “the nature of the treatment(s), expected benefits, material side effects, material risks, special or unusual risks, alternative courses of action, as well as the consequences of not having the treatment.” This never happened.
I had, and still have, no confidence that my medical and ocular needs were carefully considered. The ophthalmologist failed to deliver the promised service as contracted.
[1] Tania Amardeil quoting Dr. David Yan, Ophthalmologist-in-Chief for Sinai Health as reported in the article “Good news for Canadians diagnosed with cataracts: treatment is available”, www.healthing.ca, Postmedia Content Works, October 18, 2022