Introduction

Presbyopia, a common age-related visual impairment, presents significant challenges for individuals as they age, with major implications for both their quality of life and psychological well-being. Although surgical interventions such as monovision LASIK have been developed to address this condition, there remains a limited understanding of patient experiences, particularly in terms of the social and emotional impact of such treatments. This study aims to bridge this gap by exploring the lived experiences of patients who have undergone monovision LASIK for presbyopia, with a focus on the psychological and social dimensions of the procedure.

The 1980s saw the advent of surgical techniques aimed at reducing dependence on glasses, revolutionizing ophthalmologic practice and establishing refractive surgery as a subspecialty.¹ Initially focused on treating myopia, hyperopia, and astigmatism, this field gradually expanded to include presbyopia as an area of clinical interest.

The correction of presbyopia found its early model in “balanced vision”, or monovision, achieved through contact lenses.² This approach naturally translated to surgical techniques. However, the procedure presents notable challenges, particularly in terms of adaptation, as it introduces significant visual difficulties. The disparity in visual acuity across different distances places considerable sensory, motor, and psychological demands,^3,4 necessitating variable adaptation periods and yielding diverse perceptions of its effectiveness. Despite its widespread use, there is limited consensus on the long-term effectiveness of monovision LASIK, particularly in terms of patient satisfaction and adaptation. The lack of standardized outcome measures and the variable nature of individual responses make it challenging to assess the true efficacy of the procedure, contributing to ongoing uncertainty among both clinicians and patients.

Several studies^5–10 have explored the quality of life associated with refractive errors and their correction, aiming to bridge the gap between physician and patient perspectives. However, significant disparities persist in understanding these experiences, contributing to a notable knowledge gap in the field. For instance, Eydelman et al¹¹ analyzed data from the PROWL I and II studies, which collected pre- and postoperative feedback via online questionnaires from patients undergoing LASIK for hyperopia, myopia, and astigmatism. While patient dissatisfaction rates were low (1%–4%), the study highlighted the potential emergence of new visual symptoms, even after successful surgeries.

This qualitative study seeks to amplify the voices of patients with presbyopia who have undergone monovision LASIK, exploring the social and emotional aspects of their experiences. By capturing these perspectives, the research aims to fill a critical gap in knowledge regarding the different ways in which refractive surgery impacts individuals beyond visual outcomes, with the potential to inform future clinical practice and improve patient care.

Materials and Methods

Ethics Approval

The study complies with the Declaration of Helsinki and received approval from the Research Ethics Committee of Hospital São Paulo, Federal University of São Paulo (CEP-HSP/UNIFESP, CAAE: 19906619.3.0000.5505).

Study Design

This phenomenological descriptive qualitative study analyzed data from patients who underwent monovision LASIK refractive surgery at OFTALMAX/OPTY, Eye Hospital, Recife, PE. Semi-structured interviews with open-ended questions served as the primary data collection method. After obtaining informed consent, interviews were recorded, transcribed verbatim, and analyzed. Reporting adhered to the framework established by Tong et al (2007)¹² in the Consolidated Criteria for Reporting Qualitative Research (COREQ), ensuring transparency and rigor in qualitative research.

Sample

The sample comprised patients with presbyopia and associated hyperopia or astigmatism who had undergone LASIK surgery at least 1 year prior and returned spontaneously for annual follow-ups. All patients in the study group underwent bilateral simultaneous LASIK using MORIA SBK microkeratome and the EX500 excimer laser (Alcon/WaveLight, Fort Worth, TX, USA). The correction was performed using wavefront-optimized profile and the planned treatment was the total correction of static refraction in both eyes with the addition of +1.75 D in the non-dominant eye. Participants were selected via convenience sampling based on their visits to the clinic. No stratification was applied based on sex, surgical retreatment, or surgical outcomes.

Inclusion Criteria

Patients without associated eye diseases and achieving preoperative visual acuity of 20/20 (Snellen chart) and Jaeger 1 with adequate correction in each eye and uncorrected near visual acuity of Jaeger 3 or worse in both eyes. After surgery, the inclusion criteria included uncorrected distance visual acuity of 20/20 in the dominant eye and uncorrected near visual acuity of Jager 1 in the non-dominant.

Exclusion Criteria

Patients with uncorrected distance visual acuity worse than 20/20 in the dominant or worse than J1 in the non-dominant eye. Patients with surgical or postoperative complications or conditions causing visual impairment unrelated to refractive errors. Patients were contacted and scheduled for interviews at mutually convenient times. No active chart review or patient recruitment was undertaken, and no patients refused participation. Sampling ceased once data saturation was achieved, as defined by Turato (2013)¹³ when new interviews no longer yielded novel information relevant to the analysis. Exclusion criteria were established to ensure that the study focused on participants who had undergone a successful monovision LASIK procedure and had no complicating factors that could confound the findings related to the surgery’s effectiveness and emotional impact. To ensure anonymity, interviewees were assigned pseudonyms derived from Greek mythology. Male participants were named Apollo, Dionysus, Hermes, Geras, Kratos, Anteros, Helios, and Enyo, while female participants were named Themis, Hera, Athena, Artemis, Aphrodite, Hebe, Thetis, Nike, and Iris. The names were symbolic and bore no relevance to the interview content.

Interviews

A semi-structured interview guide with open-ended questions was developed and pilot-tested with three patients. The pilot confirmed the appropriateness of the questions and ensured that the interviewer avoided leading responses or disrupting conversational flow. The interview guide included questions related to participants’ motivations for surgery, the emotional impact of presbyopia, their experiences during the recovery process, and post-surgical satisfaction.

The interviews were conducted by a 21-year-old female medical student (MAA) who had received prior training from one of the authors, a PhD professor of qualitative methodology at the Federal University of Pernambuco. Initially, interviews were performed in person at the OFTALMAX/OPTY clinic, with one to two interviews conducted per day. Due to the COVID-19 pandemic, subsequent interviews were conducted via videoconferencing using the WhatsApp platform. Approximately half of the interviews were face-to-face, and the remainder were virtual. All interviews lasted approximately 30 min, and no interviews required repetition. Participants were provided with both oral and written information about the study and signed an informed consent form, which included the provision for the publication of anonymized responses/direct quotes. Conversations were recorded on the interviewer’s smartphone and transcribed on the same day. Transcripts were not returned to participants, as this was deemed unnecessary and unlikely to impact participant well-being. Although the transition to videoconferencing was necessary because of COVID-19, there were no significant differences in the quality or depth of responses between the face-to-face and virtual interviews.

Analysis

ATLAS.ti software (version 9.1.1)¹⁴ was used to systematically organize and categorize the interview data, allowing for efficient identification of key themes and ensuring consistency in the coding process. The data were analyzed using thematic content analysis, as described by Turato.¹³ This methodology involved the following steps:

Preanalysis

A series of free-floating readings was conducted to identify underlying meanings, including those not explicitly stated.

Categorization and Subcategorization

Key themes were highlighted based on relevance and frequency of occurrence. Data were then reorganized into structured categories and subcategories, transforming raw information into organized, coherent data.

External Validation

To ensure consistency and rigor in the analysis, two researchers independently coded a subset of the data and compared results to reach a consensus on key themes.

Presentation of Results

Results were presented descriptively, supported by illustrative quotations from participant interviews, which served as the foundation for subsequent discussion, inference, and interpretation.

Discussion

According to Turato,¹³ this phase involves reinterpreting and reorganizing data in innovative ways through imagination and critical analysis. The goal is to deepen understanding of the study subject and propose new concepts and theories to provide meaningful insights for the academic and clinical community.

The collaborative review process helped validate the findings and provided multiple perspectives on the interpretation of key themes, adding depth and richness to the analysis.

Results

The average age at the time of surgery was 50.3 years and 53 during the interviews. A total of 17 participants (9 women and 8 men), aged 48–60 years, were included. Of these, 8 interviews were conducted face-to-face, and 9 were conducted via videoconferencing. Seven participants had completed higher education, while 10 had attained a high school education level. Tables 1 and 2 summarize the clinicodemographic characteristics of the cohort. The variations in education level and sex in the sample may have contributed to differing perspectives on the emotional impact of presbyopia and the perceived effectiveness of monovision LASIK. For instance, individuals with higher education may have expressed more detailed insights into the procedure’s benefits, while sex differences may have influenced how participants viewed the social implications of the surgery.

Table 1 Clinical Data of the Interviewees

Table 2 Age at the Time of the Interview and Status of Eyes Before or After 1 year

From the 17 interviews, 364 citations were identified and coded. These citations were categorized into 22 initial codes, which were further grouped into 5 broader code categories. The citations were analyzed and grouped into themes using ATLAS.ti software, ensuring that key concepts were systematically identified and coded based on their relevance to the research questions. These groups served as the basis for the final thematic report, which identified key themes and sub-themes that emerged organically from the data. The five broad categories identified through the coding process were related to participants’ motivations, experiences with the procedure, emotional impact, social implications, and recovery challenges. Tables 3–7 present the themes, sub-themes, and two illustrative citations for each sub-theme. Illustrative citations were chosen based on their ability to clearly represent the key themes and provide insight into the common experiences shared by participants. The tables include the thematic categories, along with representative sub-themes and supporting quotes that illustrate the diversity of participant experiences.

Table 3 Theme 1: Time and Presbyopia – Its Causes and Implications

Table 4 Theme 2: Motivational Factors for Seeking Surgical Management of Presbyopia

Table 5 Theme 3: The Fear of Surgery and Overcoming It

Table 6 Theme 4: Sacrifice and Adaptation

Table 7 Theme 5: The Effect of Surgery

Discussion

We aimed to conduct a phenomenological analysis of the onset of presbyopia and its correction through LASIK monovision. Following the example of other qualitative studies in ophthalmology,^15–17 we explored the phenomenology of age-related near-vision loss and treatment approaches chosen to address this condition. Although qualitative methods remain underutilized in ophthalmology, they offer a unique and valuable perspective for investigating the quality of life of patients undergoing such experiences.

Presbyopia is a nearly universal condition, affecting a large portion of the global population, with significant social, economic, and mental health repercussions. A systematic review estimated the global prevalence of presbyopia at 54.7%–90% among adults aged ≥35 years, with women, individuals with hyperopia, and those of shorter stature disproportionately affected.¹⁸ Emotional responses to presbyopia, including feelings of inadequacy (15%) and embarrassment or shame (7%), are also notable.¹⁸ The present findings align with these data, showing a slight predominance of women and universal hyperopia among participants. With an average age of 50.3 years at the time of surgery and 53 years during the interviews, this age range provided an adequate interval to assess the surgical outcomes and allowed for an enriched qualitative understanding of the patients’ experiences. The predominance of women in this study may have influenced the psychosocial themes discussed, with some female participants expressing more concern about the social implications of presbyopia and its treatment. Additionally, the higher education levels of some participants could have contributed to more nuanced perspectives on the procedure’s benefits and risks; this may be relevant when considering the broader applicability of the findings.

Time and Aging: The Psychosocial Impact of Presbyopia

The loss of near vision is commonly perceived as part of aging, representing a key life milestone. As Enyo vividly remarked: “I was exactly 40 years old, of course!” While some participants sought alternative explanations, such as heredity or visual strain, most linked presbyopia to the natural aging process. Hermes summarized this sentiment: “Time passes with wear and tear in all circumstances”. The perception of presbyopia as an inevitable aspect of aging aligns with broader psychological theories of aging, such as Erikson’s stages of psychosocial development,¹⁹ where the awareness of physical decline can impact an individual’s sense of integrity or despair.

This perception of presbyopia as a natural but disruptive event aligns with the findings of Kandel et al (2018),²⁰ who reported similar testimonies. The dissonance between biological and chronological age—a phenomenon observed in this study—has also drawn attention from neuroscientists exploring “epigenetic clocks”, which use molecular markers to estimate biological age.^21–23 Such research underscores presbyopia’s role in shaping self-perception and may further motivate patients to seek surgical solutions, as explored in the second theme:

Motivational Factors for Surgery

Hygiene emerged as a notable subtheme of the second theme, likely due to the overlap of this study with the COVID-19 pandemic. Twelve citations occurred after pandemic-related restrictions were implemented. This aligns with Joffe’s²⁴ observation that the demand for refractive surgeries has increased post pandemic, driven by issues such as foggy glasses, concerns about contact lens contamination, and the desire for improved appearance during video calls. Interestingly, while eyeglasses were often seen as inconvenient or unattractive, sunglasses were positively perceived as aesthetic accessories—highlighting their symbolic value in contrast to near-vision spectacles.

Aesthetics was another prominent motivator, as beauty is a powerful, albeit subjective, driver of decision-making. Scruton²⁵ argued that beauty is not superficial but central to personal choices, influencing not only self-perception but also broader psychosocial dynamics. The eyes, central to facial aesthetics, play a crucial role in defining individuality and self-expression. Surgical correction of presbyopia, therefore, extends beyond mere functionality, addressing deeper emotional and symbolic concerns.

While aesthetics and hygiene were primary motivators for many participants in this study, cultural or socioeconomic factors may have influenced the weightage given to these concerns. For example, in some cultures, the perception of beauty and appearance may hold more significance, and this could lead to different motivational drivers for surgery.

Discomfort, dependence on glasses, and frequent forgetfulness of the accessory further reinforced participants’ motivations for surgery. Geras likened dependence on glasses to addiction: “It’s like you’re addicted to something [.] You have an obligation to wear glasses”. Additionally, the growing importance of near vision in daily life—driven by the widespread use of digital devices—further validated the desire for surgical correction.

Fear of Surgery: A Universal Barrier

Fear of ophthalmic surgery was a nearly universal feeling, as observed in this study and corroborated by the literature. Alhibshi et al²⁶ reported that fear of complications deterred 14.1% of medical students in Saudi Arabia from considering refractive surgery. Interestingly, 50.3% expressed distrust due to the observation that many ophthalmologists themselves wore glasses. Similarly, a Brazilian study identified ineffective communication between physicians and patients, with 60% of respondents reporting that refractive surgery was never discussed during ophthalmology consultations.²⁷

Overcoming fear often requires external encouragement. The influence of friends and family played a decisive role, as exemplified by Hera: “My sister and brother both had the surgery and encouraged me to do it, without fear!” This dynamic echo the archetype of the “hero”, as described by Peterson (1999).²⁸ The hero represents transformative adaptation, turning the unknown into opportunity. In this context, the “hero” often took the form of a friend, relative, or colleague who shared their positive surgical experience, inspiring others to follow.

The influence of friends and family on overcoming surgical fears highlights the importance of trust in not only the procedure but also the medical professionals performing it. Patients often rely on personal recommendations and shared experiences to mitigate their concerns; this underscores the need for strong patient–physician relationships built on trust and clear communication.

Sacrifice and Adaptation: The Path to Satisfaction

The process of adaptation formed the fourth theme, marked by challenges such as worsened distance vision, night light distortions and loss of productivity. All patients complained of optical disturbances caused by lights at night and – to emphasize the importance of the phenomenon – we called this set of complaints “the night terrors”, but we do not directly question the characteristics of light distortions, which could be probably classified into halos, glare and starbursts²⁹ – after all, quantifying the incidence of these phenomena was not the objective of the research. This side effect is consistent with Goldberg’s (1985)²⁹ and Evans (2007)³⁰ early warnings about the optical effects of monovision LASIK in hyperopic patients, and participants also frequently described headlights and streetlights as disorienting, a phenomenon partly explained by the Pulfrich effect,⁴ which distorts depth perception due to delayed visual processing in one eye.

Adaptation times to these unwanted effects varied widely among participants, from as short as 30 days to as long as a year. The variation in adaptation times observed in this study may be partially explained by psychological factors such as personality traits. Patients with more flexible personalities may be more adaptable to the changes introduced by monovision LASIK, while those with higher expectations or perfectionistic tendencies may struggle with the adaptation process.

Surgical Outcomes: Freedom and Final Judgment

The fifth and final theme focused on the effects of surgery, with “freedom” emerging as a dominant subtheme. Participants celebrated their newfound independence from glasses, with Dionysus noting: “The question of freedom! That you no longer depend on glasses.”

Beyond practicality, the psychological benefits of freedom were evident, aligning with findings from Berdeaux et al,³¹ who used the Freedom from Glass Value Score (FGVS)³² to assess postsurgical satisfaction and described patients consistently reporting improved self-esteem and quality of life after abandoning glasses. However, not all participants shared this sentiment. Helios, the sole dissenting voice, described the surgery as unnecessary, reminding us of the importance of careful patient selection and individualized care.

As Bardin (2011)³³ argued, even a single contradictory opinion holds value, challenging assumptions and emphasizing the need for a patient-centered approach. Helios’ perspective highlights the importance of understanding patient expectations and prioritizing their unique needs during surgical consultations.

Limitations and Clinical Implications

Our study presents several notable limitations. As observed in the qualitative research by Blancafort Alias et al (2022),³⁴ the COVID-19 pandemic interrupted in-person interviews, necessitating a shift to video calls to ensure the continuation of the study. This change likely influenced the perceptions of participating patients, particularly regarding hygiene as a motivational factor, which was more frequently cited in video interviews. Another limitation, perhaps the most critical, is the presence of only one dissatisfied participant regarding the outcomes of LASIK monovision. We acknowledge that including more divergent perspectives would have enriched the findings and discussion.

However, we argue that dissatisfied individuals often refrain from attending to follow-up appointments or participating in interviews of this nature. Given the choice between waiting for more spontaneous returns—feasible only after mandatory restrictions were lifted—or proceeding with one dissenting voice to represent a broader group, we chose the latter. This decision underscores a fundamental difference between qualitative and quantitative research: in qualitative studies, the depth and richness of individual accounts take precedence over sample size. This distinction may be challenging for readers less familiar with qualitative methods, particularly ophthalmologists, who are typically more accustomed to data-driven numerical analyses in academic literature.

Despite these challenges, the qualitative exploration of presbyopia and LASIK monovision represents a novel contribution to the scientific literature. This alternative perspective on refractive surgery provides valuable insights for the medical community, enhancing understanding of the psychological and social impacts of presbyopia and helping identify personalized factors for selecting surgical candidates. For these reasons, we believe our study offers meaningful contributions to the treatment of this unavoidable condition, which ophthalmologists address on a daily basis.

Conclusion

This study highlights the psychosocial impact of presbyopia and the potential of LASIK monovision to address both visual and emotional challenges. Although the procedure is effective for many, the study notes the need for further research to include more patients with negative outcomes. It emphasizes the importance of considering individual motivations and psychological factors during candidate selection. Ophthalmologists should personalize consultations, addressing both functional and emotional needs, providing clear information, understanding patient concerns, offering support, and setting realistic expectations to build trust and improve satisfaction.