Cataract Surgery and Consent: When Montgomery Is Tested in Practice

Eye Procedure

Consent in cataract surgery is rarely about whether a form was signed. In medico-legal practice, it is about whether the patient was placed in a position to make a genuinely informed decision, taking into account their individual circumstances, priorities, and risks.

This blog is written for surgeons, medical experts, and those involved in medico-legal assessment. Its purpose is to explore how consent in cataract surgery is examined retrospectively by the court, and why technically competent surgery can still give rise to successful claims when consent is inadequately handled.

Consent Is a Process, Not an Event

In cataract surgery, consent is often treated as a discrete step rather than a process. From a medico-legal perspective, this is where difficulty begins.

Courts do not assess consent by asking whether a standard list of risks was recited. They examine whether the discussion was tailored to the patient in front of the surgeon at that time. This includes consideration of lifestyle, occupation, visual reliance, comorbid eye disease, and tolerance of risk.

Expert witnesses are frequently asked to determine whether consent was meaningful, rather than merely documented.

Material Risk Is Patient-Specific

One of the most common errors in cataract consent is assuming that low statistical risk equates to low importance.

From a legal perspective, a risk may be material if:

• it would be significant to that particular patient, or

• the surgeon knew, or should reasonably have known, that it would be significant

In cataract surgery, this commonly applies to:

• loss of vision in a patient with good fellow-eye dependence

• refractive surprise in patients with strong spectacle expectations

• dysphotopsia in those who drive at night

• prolonged recovery in patients with occupational time pressures

Consent must address what matters to the patient, not what the surgeon considers routine.

When Standard Wording Is Not Enough

Consent forms are often well constructed but poorly contextualised. In litigation, expert witnesses frequently encounter consent documentation that lists complications accurately but fails to reflect the discussion that should have taken place.

Common shortcomings include:

• no record of refractive aim discussion

• no documentation of alternatives such as deferral or non-surgical management

• no reference to second-eye planning

• no acknowledgement of ocular surface disease or other modifying risk factors

When documentation does not reflect the complexity of the clinical decision, courts may infer that the discussion itself was similarly limited.

Refractive Outcomes and Consent

Increasingly, cataract surgery is viewed by patients through a refractive lens. This has shifted the consent landscape significantly.

Issues frequently scrutinised include:

• whether refractive unpredictability was discussed

• whether monovision or mini-monovision was explained

• whether the limitations of biometry were addressed

• whether post-operative spectacle dependence was clearly communicated

Expert witnesses are often asked to assess whether the surgeon adequately explained that refractive outcomes cannot be guaranteed, even with appropriate planning.

Timing and Environment of Consent

Consent obtained on the day of surgery or immediately before listing often attracts scrutiny. Courts consider whether the patient had sufficient time to reflect, ask questions, and reconsider their decision.

Factors that may undermine consent include:

• consent obtained under time pressure

• lack of access to written information

• language barriers without appropriate support

• reliance on generic information rather than tailored discussion

The environment in which consent is obtained matters almost as much as the content.

Capacity, Vulnerability, and Cataract Surgery

In some cases, particularly involving elderly patients, capacity and vulnerability become central to the consent analysis.

Expert assessment may be required where there is:

• cognitive impairment

• reliance on family members for decision-making

• sensory impairment affecting understanding

• complex risk profiles

Consent in these cases requires additional care, clarity, and documentation.

How Courts Examine Consent Retrospectively

When a cataract outcome is poor, courts do not ask whether the surgeon intended to act appropriately. They ask whether the patient would have proceeded with surgery had they been properly informed.

Expert witnesses must therefore consider:

• what the patient knew at the time

• what was reasonably foreseeable

• what alternatives were available

• whether risk information was balanced and comprehensible

This analysis requires neutrality and avoidance of hindsight bias.

Teaching Point for Surgeons and Experts

Cataract surgery consent fails not because surgeons are careless, but because routine practice drifts away from individualised discussion.

For surgeons, robust consent protects patients and clinicians alike.For expert witnesses, careful analysis of consent is essential to assist the court in understanding whether a patient’s autonomy was respected.

Conclusion

Consent in cataract surgery is increasingly central to medico-legal scrutiny. As patient expectations rise and refractive outcomes gain prominence, the standard for meaningful consent continues to evolve.

Understanding how consent is tested in practice allows clinicians to improve care and enables expert witnesses to provide clear, balanced, and court-compliant opinions. When consent is treated as a thoughtful process rather than a procedural formality, both patients and practitioners are better protected.