This is the personal essay among the more clinical articles on this site. I’ve thought about putting it down for some time, and the request to mark twenty years in practice was the right occasion.
The lessons that matter most to me as a surgeon — the ones that shape how I work today — are not the technical ones. The technical knowledge is the floor. What matters more, decades in, is the framework that surrounds the technique.
The right surgery at the wrong time is the wrong surgery
This is the lesson I would put first. Patients sometimes arrive convinced that surgery is the answer, having read about it or heard about it from a friend. The cataract is small. The dry eye hasn’t been worked up properly yet. The LASIK candidacy is borderline because of mild dry eye that wasn’t fully addressed.
It takes longer to explain why now is not the right time than to schedule the procedure. But scheduling a procedure when the patient and the eye aren’t ready produces results that disappoint everyone — including, eventually, the patient who wanted it.
Most of what I do as a surgeon is decide whether to operate, and on what timeline. The actual operating is the easy part once the decision is right.
Time spent explaining is not time wasted
Every patient deserves to understand what is happening to their eyes, what the options are, and what each option’s trade-offs really are. This takes time. There is no efficiency tool that substitutes for it. A consultation that runs an hour and a half because the patient had ten thoughtful questions is the right consultation.
I notice that my long-term outcomes — patient satisfaction, surgical results, the relationships that bring patients back for the next decade — track most closely with the time I take pre-operatively, not the time I take in the operating room.
The eye does not exist alone
The eye is part of a person who has high blood pressure that makes their corneas thinner, who has diabetes that affects their healing, who has a complicated grief that means their tear film is changed, who has a job that requires excellent night vision, who has a partner who is helping them navigate a recent diagnosis. The decision about cataract surgery, or LASIK, or how aggressively to treat glaucoma, depends on all of these.
An ophthalmologist who treats only the eye misses the patient. A surgeon who recommends a multifocal IOL without asking whether the patient drives at night for a living is doing arithmetic, not medicine.
Honest answers, even when they’re difficult
“Your eyes are not good candidates for LASIK.” “Your cataract isn’t ready for surgery.” “Your glaucoma is progressing despite the drops, and we need to talk about laser.” “I think you have a condition that’s larger than the eye, and I’m going to refer you to a colleague.”
None of these are easy to deliver. None of them are also avoidable. The patient who is told the honest answer trusts the next conversation. The patient who is told what they want to hear, when it’s not true, learns later that they couldn’t trust the first conversation either.
Continued learning is the floor
Refractive surgery in 2026 is dramatically different from refractive surgery in 2005. Cataract IOL technology has expanded into options that simply did not exist when I started. Glaucoma surgery now includes minimally-invasive procedures that have transformed the early-disease treatment landscape. Anti-VEGF injection therapy revolutionized AMD treatment.
An ophthalmologist who learned techniques twenty years ago and stopped is offering twenty-year-old care. The expectation in this field — and I would argue the obligation — is continued learning. Conferences. Journal reviewing. Hands-on courses on new techniques. Conversations with colleagues about what they’re seeing.
Quiet confidence is the goal
The new surgeon’s challenge is overconfidence; the experienced surgeon’s challenge is its opposite. The right place is in between: enough confidence to make decisions and stand behind them, enough humility to recognize what you don’t know and to seek help when needed.
The patient deserves a surgeon who is calm in the moment, candid about uncertainty, decisive about what’s clear, and willing to slow down when slowing down is the right call.
The patients who make the work worth doing
I’ve been doing this for over twenty years. The reason I’m still doing it is the patients. The patient who can drive at night again after cataract surgery and tells me their world feels different. The patient with optic neuritis who learns it’s not progressive. The young patient with high myopia who has ICL surgery and walks in for the first follow-up not wearing glasses for the first time in their adult life. The elderly patient with macular degeneration who learns there are tools that will help them keep reading.
This is the work that matters. The technique exists to serve it.
What I’d tell a new ophthalmologist
Take the time. Don’t rush the consultations. Tell the truth even when it’s hard. Stay current with the technology. Treat the patient, not just the eye. Recognize that surgery is one tool in a much larger toolbox, and the larger toolbox is what defines a good ophthalmologist.
And remember: the patient is trusting you with their eyes. There is almost no greater responsibility in medicine. Earn it every visit.
— Ivey L. Thornton, MD
