I wish I hadn’t done that: Pick a lane
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This column is the latest article in the ongoing series “I wish I hadn’t done that.” Past submissions can be read here.
Bruce Lee, arguably the greatest martial artist of all time, once famously said, “I fear not the man who has practiced 10,000 kicks once, but I fear the man who has practiced one kick 10,000 times.”
While my own operations are only occasionally as bloody as a fistfight in the streets, I have found Lee’s sage wisdom to be nevertheless applicable. Variety is not itself a virtue.
The major source of variety in my surgeries lately owes to the ceaseless outpouring of new IOL technologies. These include new monofocal designs, so-called extended depth of focus lenses, multifocals and entirely new entities such as the pinhole aperture lens. These various IOLs all advertise different optical profiles and compete along only vaguely intelligible dimensions such as spherical and chromatic aberration. Theoretically, the savvy surgeon can mix and match IOL types to diverse circumstances, customizing the lens not only for the patient’s refractive preferences but also for the optical parameters of the eye, considering such abstruse variables as chord mu, the so-called Gullstrand ratio, angle kappa and angle alpha.
For a while, I played this game. I would head for the operating room with 10 different types of IOLs for any given day. Initially, this felt like technological sophistication, and I was reinforced in this belief by the reps from all these IOL companies, who were naturally enthusiastic about my choices.
Consequently, the simple act of picking an IOL quickly became enormously complex, ie, trying to reconcile a huge array of diverse inputs to customize a lens, not only for the parameters of the patient’s eye but also for their personality.
And what was the payoff for all this extra work? The punch-in-the-gut result was refractive surprises everywhere. Over the past 2 years of my career, I have never had more refractive misses, more disappointed expectations and fewer happy patients. All this extra fiddling has backfired completely.
The problem, in retrospect, has been the delusional belief that I could rationally parse an infinity of variables to choose from an ocean of lenses. Ironically, these attempts at over-customization just interjected randomness into my outcomes because jumping from lens to lens has prevented me from learning enough about any single technology to learn it effectively. These lenses are indeed different, and casual sampling of all of them, all the time, does not conduce to intimate knowledge of their effects.
The point I am trying to make is not “don’t try new lenses” or even “don’t use multiple different lens designs.” Rather, I mean only to share my own personal experience with over-customization, which has resulted in worse outcomes because it stymied my ability to learn from experience. All or most of the lenses currently on the American market are reasonable technologies, but jumping back and forth among them is a less reasonable strategy than picking a small number and becoming expert on their use. Put another way, you probably do not want a doctor who, for some very sophisticated and complicated reasons, thinks you are a great candidate for such-and-such lens, but in actual practice, he has implanted the thing only eight times, ever.
Since achieving this realization, I have swapped over to using a “standard lens” for almost all my surgeries. Forgoing all this complexity has not only resulted in better refractive outcomes for my patients but it has also enormously relieved my own computational burden. I feel less smart, but so far, my patients do not seem to mind.
- For more information:
- Jack S. Parker, MD, PhD, of Parker Cornea in Vestavia Hills, Alabama, can be reached at jack.parker@gmail.com.
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