Presbyopia as a Process: Why New Concepts Take Time

Although physicians are trained from the start to collect data, analyze evidence, and make rational therapeutic decisions, discussions about presbyopia correction in everyday clinical practice are rarely purely objective. Conversations with colleagues suggest that these decisions often also carry an emotional dimension. Treatment choices are not exclusively evidence-based, but also eminence-based; shaped by personal experience, familiarity with certain procedures, and trust in pathways that have been established over many years. This raises an important question: how can clinicians remain open to alternative approaches without being unconsciously bound by loyalty to familiar concepts? 

How medicine changes 

Of course, scepticism toward new treatment strategies is not unique to presbyopia correction. It's a recurring pattern across medicine. Historically, many innovations have met resistance because they challenged established thinking and prevailing definitions of safety. The history of refractive lens surgery illustrates this clearly: despite early functional benefits, refractive lens extraction - described theoretically as early as the 18th century and systematically implemented in the late 19th century by Fukala - was long viewed as a deviation from accepted doctrine. Only after years of clinical experience and accumulating evidence did cautious acceptance finally emerge (1). 

A similar trajectory can be seen in trauma surgery. The intramedullary nail initially faced strong scepticism because it contradicted prevailing principles of anatomical perfection and external immobilization. Developed by Gerhard Küntscher, the technique was criticized for potential axis deviations, biological risks, and the perceived abandonment of radiological ideals. Only when its functional advantages such as earlier mobilization and improved rehabilitation, became undeniable did intramedullary nailing gain broader acceptance and eventually become the gold standard for treating long bone fractures (2). 

These examples highlight a central truth: medical progress rarely follows a linear path. New concepts are not evaluated solely on theoretical plausibility or even on evidence-based medicine standards, but also by how well they fit into existing mental models, experiential frameworks, and the profession’s need for safety. In this sense, scepticism can then be viewed as an expression of responsibility. It becomes a barrier, however, when it prevents alternative, less invasive, or more flexible strategies from even being considered. 

Why we resist 

We can choose to examine this reluctance through the useful lens of the psychology of medical decision-making. Established therapies do not instantaneously become routine; gradually, over time, they become part of professional identity (3). What has “proven itself” comes to represent competence, experience, and responsibility. Against this background, new concepts may be perceived - often unconsciously - not as neutral alternatives, but as a critique of earlier decisions. The threat is less scientific than personal: it can feel like a challenge to one’s professional self-concept. 

Naturally, there is also a strong preference for the status quo. Established procedures offer predictability, efficiency, and a high degree of subjective security - for physicians and patients alike. By contrast, new methods can initially bring about uncertainty: more unfamiliar counseling, outcomes that feel harder to predict, and the burden of responsibility in situations that are less clearly defined. Psychologically, potential losses tend to weigh more heavily than potential gains. As a result, even objectively measurable advantages may fade into the background on an emotional level. 

Clear categories and linear pathways are appealing for another reason: they reduce complexity. Medical algorithms create structure in decision-making, support communication, and enable standardization. However, new concepts that have not yet found a place within existing algorithms require a departure from familiar templates and a level of individualized clinical judgment that is difficult to accommodate within tightly scheduled clinical routines. 4). 

Finally, personal clinical experience remains a powerful force. Years of practice provide confidence, and what has worked reliably is often perceived as inherently correct. New procedures must therefore prove themselves not only against published data, but also against the lived experience of surgeons (5). Innovations can meet particular resistance when they disrupt established hierarchies or challenge the implicit authority of long-standing practice. This scepticism is rarely hostility toward innovation - it is more often a normal psychological protective mechanism. 

Against this background, it becomes understandable why newly introduced intraocular lenses often gain rapid acceptance, even when extensive clinical data are not yet available at the time of their introduction (6). They integrate seamlessly into established, lens-based treatment pathways and do not require a fundamental shift in clinical decision logic. 

A similar pattern can be observed in corneal presbyopia procedures. Classical monovision is based on long-established optical principles and remains firmly anchored in refractive thinking. Its functional limitations such as reduced stereopsis, limited intermediate vision, and contrast reduction are well known and yet widely accepted, largely because the concept is familiar and easy to communicate (7). 

PRESBYOND and the challenge of non-linear thinking 

PRESBYOND, a minimally invasive corneal procedure for presbyopia correction, departs from conventional monovision concepts by adopting a binocular, neuroadaptive approach. Rather than relying on strict interocular refractive disparity, it expands depth of focus through the controlled induction of spherical aberrations in both eyes, thereby minimizing the limitations typically associated with monovision (8). Paradoxically, it is precisely this conceptual advancement that can trigger hesitation; not because the optical principles are unfamiliar, but because the approach challenges the comfort of clear categories and linear thinking. Therefore, PRESBYOND demands less a technical leap than a dynamic shift in how clinicians think about timing and sequencing in presbyopia care. If presbyopia is understood as a functional process that progresses over many years and varies between individuals, rigid “either–or” categories become less convincing.  

From this perspective, it is reasonable to view presbyopia correction as a complementary, longitudinal process that reflects both the progressive nature of presbyopia and the patient’s evolving needs. Corneal- and lens-based procedures need not compete; rather, they can meaningfully complement one another when guided by visual requirements, expectations, and life circumstances. Once accepted and integrated into clinical practice, this approach reduces decision pressure and shifts the focus away from selecting a single “best” method toward forward-looking planning throughout the patient’s presbyopic journey. 

Presbyopia moves to center stage 

If medical thinking is rooted in experience, routine, and responsibility, then expanding it is rarely a sudden event; it is a gradual process. In light of this, it's encouraging that presbyopia has become a clear thematic focus at the recent ESCRS Winter Meeting. This signals not only the growing clinical relevance of the topic, but also a willingness to discuss presbyopia correction in a more differentiated, interdisciplinary way and beyond rigid categories. That creates space for the kind of reflection required to evolve established thinking and to contextualize new concepts appropriately, making room for innovation. 

At the same time, it highlights how clinical models can expand: by understanding new approaches not as replacements, but as complements to existing strategies. Ultimately, this shift in perspective determines whether innovation is experienced as a threat or else recognized as an opportunity.