Personalizing Cataract Surgery: Aligning Patient Preferences and Ocular Characteristics | Neda Shamie, MD

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If you’ve ever heard the words “you need cataract surgery”, you know what usually comes next.

“What kind of lens should I get?”

And I get it—patients feel overwhelmed, and honestly, a lot of doctors do too. Monofocal. Toric. Multifocal. Extended depth of focus. Light adjustable. Small aperture. It can sound like an endless menu… and it’s easy to feel like you’re supposed to pick the “best” one without really knowing what “best” even means.

That’s why I was so excited to sit down with one of the top names in cornea and cataract surgery: Dr. Neda Shamie—a board-certified ophthalmologist and partner at Maloney-Shamie-Hura Vision Institute of Los Angeles, one of the most respected refractive practices in LA. She’s helped over 10,000 patients regain clear vision, and she’s known for something I love: she doesn’t treat lens selection like a template. She treats it like a custom fit.

And in this conversation, she walks us through the exact mental framework she uses—how she thinks, how she screens, and how she “matchmakes” lens technology to a person’s anatomy, lifestyle, and expectations.

Cataract surgery isn’t what it used to be

Dr. Shamie and I both trained in an era when cataract surgery was considered a success if:

• the cataract came out

• the lens implant went in the bag

• there was no infection or major complication

• and the patient got glasses a few weeks later

Today, that definition has changed.

Modern cataract surgery—especially in a refractive-focused practice—is about more than removing cloudiness. It’s about helping patients function in a world that demands distance vision, mid-range vision (computer), and near vision (phone/text/reading)—often within seconds of each other.

As Dr. Shamie put it, refractive cataract surgery is a modern way of thinking: not just “clear the cataract,” but optimize lifestyle, reduce dependence on glasses, and meet patients where they are today—active, traveling, digital, and expecting high quality.

Surgical success today = a happy patient (and that’s subjective)

One of the best parts of our conversation was how honest she was about what success means now.

A “happy patient” (especially in a place like West LA) often wants:

• high-quality vision at all distances

• minimal or no dependence on glasses

• the ability to drive at night without bothersome glare/halos

• crisp, bright vision with strong contrast and color

Is that possible for everyone? No. And that’s where experience matters—because the limitation isn’t always the surgeon or the lens. Sometimes it’s the anatomy of the eye, the health of the retina, the ocular surface, or other conditions that simply cap what’s achievable.

But what stood out to me most was her emphasis on the relationship: patients do best when they don’t feel like they’re being pushed through a “surgical mill.” They do best when the process feels custom, and when expectations are set early and reinforced consistently.

The relationship starts before the patient ever walks in

This is a big lesson—especially for surgeons and practices.

Dr. Shamie explained that lens counseling doesn’t begin in the exam room. It begins:

• with education on the website

• with social media, podcasts, and patient materials

• through the referring optometry/ophthalmology network

• and even through trained technicians who start the conversation the right way

Because patients don’t choose you after they learn your process—they choose you because they can already tell what you value.

Her non-negotiables before premium lenses

If you’re considering a premium lens, Dr. Shamie is very clear: outcomes are only as good as your data.

Her baseline “must-haves” include:

1) Corneal topography/tomography
Not optional. This helps evaluate:

• ocular surface quality and tear film stability

• regular vs irregular astigmatism (critical for torics)

• whether the cornea is “trustworthy” enough for premium optics

2) Advanced biometry (she uses IOLMaster 700)
Because in refractive cataract surgery, precision matters—small misses can be felt more with premium optics.

3) Macular OCT
This one is huge. She considers it non-negotiable, especially for premium lenses, because subtle conditions like epiretinal membranes (ERM) can be missed clinically yet absolutely impact patient satisfaction.

The biggest deal-breaker: ocular surface disease (dry eye, lid disease)

If there’s one “red flag” theme that kept coming up, it was this:

You cannot ignore the ocular surface.

Dr. Shamie is aggressive about diagnosing and treating it before measurements. Because if your tear film is unstable, your cataract calculations can be unreliable—and premium lenses are less forgiving when you miss the target.

Her step-by-step approach is very practical:

• Rule out Demodex blepharitis (look for collarettes at lash bases)

• Assess tear breakup time and tear quality

• Check for punctate staining (especially central staining)

• Delay measurements if the cornea is compromised and the patient is pursuing premium optics

• Treat thoughtfully: artificial tears, anti-inflammatories (like cyclosporine/lifitegrast), punctal plugs in the right context, and in severe cases even amniotic membrane

And here’s a nuance I appreciated: she’s cautious about premium lenses in moderate-to-severe dry eye patients not because they can’t improve—but because many patients become less compliant after surgery. That’s how you end up with someone who “invested in a Ferrari” but can’t drive it the way it’s meant to be driven.

Who is not a good premium multifocal candidate?

She made an important distinction:

• Toric monofocals can still be appropriate for many patients with comorbidities (like macular degeneration) if there’s meaningful regular astigmatism.

• But multifocal and presbyopia-correcting optics are different, because they can reduce contrast and amplify issues when the visual system is already compromised.

Relative or definite contraindications (depending on severity) include:

• moderate/advanced glaucoma

• macular degeneration (especially more than mild)

• epiretinal membrane (more than mild)

• significant corneal irregularities (EBMD, Salzmann nodules, pterygia—depending on stability and counseling)

• zonular weakness/pseudoexfoliation (case-by-case)

• and yes—personality and visual sensitivity (engineers, photographers, performers on stage lights)

Not because these patients “can’t” do well—but because they’re more likely to notice subtle optical tradeoffs and be less tolerant of visual phenomena.

Her “cheat sheet” approach: stop overwhelming patients

This was one of the most practical takeaways for surgeons and practices.

Instead of techs listing every possible lens option (which creates confusion and decision paralysis), Dr. Shamie trains her team to look for history clues that funnel patients toward the most likely best option—then spend the dilation time educating on that one lens.

Her examples:

1) Prior refractive surgery (LASIK/PRK/RK)

These patients have a higher risk of refractive surprise. Her go-to: Light Adjustable Lens (LAL), because it allows postoperative refinement.

Key counseling point: LAL is not a true multifocal. It can provide range via mini-monovision strategies, but it’s not automatic “all distances without glasses.”

2) The myope who loves reading without glasses

If they take glasses off to read and want freedom at all distances: a trifocal is often the only option that matches that lifestyle (assuming no contraindications).

She specifically highlighted how much newer trifocals have improved—patients reporting less night glare/halo complaints than earlier generations.

3) Patients who loved monovision in contacts

If they truly tolerated monovision well: LAL can be excellent to dial in that “sweet spot.” If not LAL, then an extended-range option with mini-monovision may be considered depending on the eye.

4) High astigmatism + comorbidities

Often: toric monofocal, because it improves clarity even if the patient isn’t a multifocal candidate.

And for astigmatism correction, she shared a very specific threshold:

• Against-the-rule: toric starting around 0.75 D

• With-the-rule: toric starting around 1.0 D

Lens-by-lens: how she thinks about pros/cons

Here’s the simplified “in her mind” overview:

Light Adjustable Lens (LAL)

• Pros: refine target after surgery, great for post-LASIK/PRK/RK, great for engineers/precision personalities, can do monofocal toric version

• Cons: higher cost, multiple visits, time commitment, not inherently “all distances” unless using monovision strategy

Trifocal / multifocal (e.g., PanOptix-class lenses)

• Pros: highest potential for true glasses independence at distance/computer/near

• Cons: must hit refractive target; residual astigmatism or surface disease can reduce satisfaction; possible night symptoms (though she reports far fewer with newest designs)

Extended range (EDOF / “range” lenses like Vivity-class)

• Pros: more forgiving than multifocals in mild comorbidity cases; strong distance + computer

• Cons: may not deliver the same near vision as trifocals; some patients describe “waxy” vision

Toric monofocal

• Pros: excellent quality, especially for patients okay with readers; still valuable even with macular disease when astigmatism is meaningful

• Cons: doesn’t solve near dependence on glasses unless paired with monovision strategy

Small aperture lens

• She likes it particularly for irregular astigmatism scenarios in a non-dominant eye, and even described pairing it with LAL in the dominant eye for post-RK patients with irregularity—with strong results.

The most important part: expectation-setting language (before surgery)

This is where you can feel how experienced she is.

Her core strategy: plant the language early so that nothing feels like a surprise later.

She tells multifocal patients:

• it may take 3–6 months to adapt

• you may notice glare/halos early on

• you may need tear film optimization during recovery

• perfection is not the goal—function and happiness are

• and if you’re in the small percentage who truly can’t adapt, she is comfortable with a lens exchange

And she avoids saying “perfect.” Instead, she frames it as: “I strive for the best outcome possible, but eyes have limitations—and we don’t always know the full story until we’re on the other side of surgery.”

That kind of clarity protects the patient, and it protects the surgeon too.

A simple question patients should ask (and surgeons should ask patients)

At the end, I asked her what one question she wishes patients would ask their surgeon.

Her answer was essentially this:

“Can I walk you through how I use my eyes in a normal day?”

Because the most valuable information often comes from hearing:

• how much time someone spends on screens

• whether they read in bed

• whether they take glasses off to read

• whether night driving matters

• what their biggest fear is (glare, halos, losing sharpness, needing readers)

She also shared something I love: sometimes she’ll ask an educated patient, “Which lens do you think fits you?” Not because the patient should decide alone—but because it reveals expectations early, and it prevents regret later.

Want to Learn More?

This is just the beginning. In upcoming episodes, we’ll explore:
-How screen time and digital habits are shaping our kids’ development
–The connection between vision and overall health
–What you need to know about common eye procedures like LASIK and cataract surgery
–Practical ways to advocate for your child’s visual needs

You can subscribe to my podcast, In Focus, anywhere you listen—or follow along on Instagram for updates and tips.

Watch this episode on Youtube right now!

Thanks for reading—and for doing what you can to protect your child’s vision, one step at a time.

– Dr. Rupa Wong
Pediatric Ophthalmologist | Surgeon | Mom of 3

This episode is brought to you by The Pinnacle Podcast Network! Learn more about Pinnacle at learnatpinnacle.com