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Correspondence
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Multifocal IOLs
To the Editor:
I read the article in Ocular Surgery News about ophthalmologists having cataract surgery in your September 1, 1999 issue (“Ophthalmologists choose lenses for their own procedures,” page 6).
I am getting to the age where the question is not if I am going to need cataract surgery, but when. I think for most ophthalmologists, it may be difficult to decide the exact time of such a procedure. The decision is complicated by what kind of IOL to opt for.
I remember when we first started to implant IOLs: we used to discuss at length with the patients the advantages of pseudophakia versus aphakia. They were told that the great step forward with IOLs was they would need only reading glasses.
Now that I have to wear reading glasses all the time, I sit on them, scratch them, lose them, break them and hate them. I wonder if the patients have the same feelings. I know if I do cataract surgery on a 60 year old, he is set for 30 years of reading glasses. Not bad when there was no alternative.
So when I started to think about my cataract and my experience with reading glasses, I started looking. Multifocal? What I heard about multifocals was not very reassuring. The general talk was that one doctor puts them in and another doctor takes them out.
However, when I started to check carefully, my findings were far different. I found that truck drivers, cab drivers and even pilots, who have perhaps the most visual demands for different times of the day or night, have been implanted with multifocal IOLs with excellent results. From little knowledge of optics, I knew there should be all kinds of symptoms of glare, contrast sensitivity in images, etc. Not only were the multifocal patients happy, but even the unhappy ones did not want the IOL removed.
Most reassuring was an ophthalmologist who had his own eyes done. He said if it were not for an occasional halo, he would think it is too good to be true. This was reassuring, considering he has a very busy cataract and laser in situ keratomileusis (LASIK) practice.
After reading and talking to other surgeons, I know that when I need an IOL, it will be a multifocal. Once I decided that, I felt very comfortable implanting multifocals in my patients. The transition was very easy and no more difficult than unifocal IOLs.
With my patients, I was prepared to answer their complaints of halos, etc. To my surprise, the only report I got was satisfaction.
The big disappointment I had with my multifocal patients was that it was lacking the “wow” factor that I saw with LASIK. When I asked my patients if they were excited that they can read a newspaper and drive a car without glasses after surgery, they seemed surprised and said, “Why do you ask?” I expected that.
According to data anecdotally reported to Allergan (Irvine, Calif.) from a group of surgeons, of the 3,500 implanted multifocal lenses, only six were explanted for the following reasons: one patient had power miscalculation; one patient did not tolerate the IOL; two patients had macula problems that could not be seen preop due to dense cataract; and two were caused by poor patient selection. In both of these patients, multifocals were exchanged for monofocals. After the exchange, one patient was fine. The second still complained of glare.
I am not a consultant nor am I paid by any multifocal manufacturer. The only interest I have is what is best for my patients and, at this time, multifocals are at the top of my list.
Jaswant Singh Pannu, MD, PA
Lauderdale Lakes, Fla.
Nerve fiber layer thinning
To the Editor:
I am somewhat disturbed by several articles I read in a recent issue of Ocular Surgery News, specifically, Vol. 17, No. 17, dated September 1, 1999.
The first article in question appears on page 28 (“LASIK study shows brimonidine provides neuroprotective effect”).
A small, double-masked study showed almost universal nerve fiber layer thinning after laser in situ keratomileusis (LASIK). Their small study showed that this was mitigated by the use of Alphagan (brimonidine tartrate, Allergan).
Their hypothesis was that raising the pressure in the eye to 80 mm or above, which all microkeratomes must do in order to make a flap, causes nerve loss in the nerve fiber layer due to either hypoxia or apoptosis of the nerve fiber layer due to a crush injury, and that Alphagan mitigates this nerve loss.
Their study was in patients where the suction time was limited to 40 seconds. How much more of a problem is this when the LASIK procedure may take 60 seconds or longer?
I think the Medical Advisory Panel and the Food and Drug Administration (FDA) should seriously consider this before approving the LASIK procedure.
A more serious question arises regarding the Intacs (KeraVision, Fremont, Calif.) procedure (“Wet lab experience crucial when training to implant Intacs rings,” page 14). Similar to LASIK, it involves a suction ring, but the pressure is elevated quite high for a much longer period of time. Also similar to LASIK, the patient’s vision blacks out and “you want to accomplish the procedure quickly because the central retinal artery is temporarily occluded.” Since the Intacs procedure requires many minutes instead of seconds, it is true that there is thinning of the nerve fiber layer due to increased pressure. I think that the Medical Advisory Panel, as well as the FDA, should take this into consideration before granting any type of approval.
We certainly don’t want this to be the thalidomide of ophthalmology.
Jack Hartstein, MD
Chesterfield, Mo.
The Chief Medical Editor responds:
The suggestion that elevation of the intraocular tension to 80 to 100 mm Hg for 30 to 60 seconds during a LASIK procedure results in significant optic nerve fiber death remains controversial and unsubstantiated. Preoperative and postoperative visual field testing have never shown consistant development of any loss of field. While further study is needed, I am quite confident nerve fiber loss after LASIK will not be the “thalidomide of ophthalmology.” Nonetheless, all LASIK and Intacs surgeons should attempt to keep the “pressure up” time to a minimum and caution is appropriate in the patient with a vulnerable nerve.
Richard L. Lindstrom, MD
Chief Medical Editor
Validity in question
To the Editor:
Your glowing report on the LTK procedure in the article published in vol. 17, no. 14 (July 15, 1999) and the subsequent action of the FDA certainly gives one pause in considering whether other articles in your publication have much validity.
Gates E. Murphy, MD
Athens, Ala.
The Editor in Chief responds:
Dr. Murphy’s succinct letter, which we publish here complete and unedited, raises a fundamental question about medical news publications. What makes a “valid” news story?
The article in question (“Studies show Ho:YAG LTK for hyperopia, presbyopia effective and safe,” July 15, 1999, page 10) summarized presentations made at the annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS). According to our standard policy, the article was sent to all the doctors quoted, and they verified that the quotes were accurate. Also according to policy, the article was sent to Sunrise Technologies for verification of factual content. The company checked the facts and also provided us with some more detailed data from the U.S. clinical study that was then being prepared for presentation to the Ophthalmic Devices Panel of the FDA.
However, the question about our articles’ validity does not seem to be based on whether we accurately report what people say. Instead, Dr. Murphy seems to consider the decision of the panel not to recommend the Sunrise Hyperion laser for approval (see “FDA panels: no to Restasis, LTK; qualified yes to LASIK,” Ocular Surgery News, August 15, 1999, page 1) to invalidate the technology and procedure.
Perhaps it did, perhaps not. A final decision has yet to be reached by the staff reviewers at the FDA. But just as it is up to the FDA panel members and staff reviewers to consider the data and make an informed decision about new technologies, we trust our readers to do the same. In this sense, we agree with Dr. Murphy. Readers should certainly pause to consider the validity of the points of view of the people being quoted in Ocular Surgery News. What we are certifying is that those views are being presented accurately and in context.
Peer-review journals have traditionally tried (with varying degrees of success) to prescribe what information should or should not be disseminated to medical professionals. We believe medical newspapers should describe everything that is going on in the medical community – good, bad and indeterminate. We know this also obligates us to publish as much data and as many balancing points of view as possible on new instruments, drugs and techniques.
In this case, we feel it was just as appropriate for us to publish the original article as it was for ASCRS to have provided a venue for the original presentations. We feel we met our further obligation to follow the story when we published the in-depth article on the FDA panel decision, and we will continue to follow the story wherever it may go.
Joseph Hoffman
Editor in Chief
Decrease in cataract surgery volume
To the Editor:
I read with great interest the article written by Henry W. Singer in Ocular Surgery News ("ASCRS survey: number of cataract procedures dropped 4.5% in 1998,” August 1, 1999 issue, page 73) in which he summarizes the results of Dr. Leaming’s survey, finding a significant decrease in cataract surgery volume for the first time since the survey began in 1984. I find this data fascinating, and although Dr. Leaming has a plausible theory as to the reason why there has been a decrease in volume in cataract surgery in the United States, I disagree and present here a second hypothesis.
Dr. Leaming states that there is certainly no shortage of cataracts, and I think all would agree that with the aging population of the United States, there should be — and is — a larger number of patients needing cataract surgery. Dr. Leaming believes that the decrease in the number of procedures is a result of an increase in the annual number of refractive procedures. He assumes that there is a finite number of procedures with which a surgeon is comfortable performing, and that as surgeons develop full-blown refractive surgery practices, they perform less cataract surgery.
This may indeed be the case in a small number of practices, but I believe that most high-volume cataract surgeons either add another surgery day or a new partner when their volume of surgery increases. Most busy cataract surgeons probably do not reach a finite number of cases with which they are comfortable, but would operate every day if they could (and this is the case in many practices). Despite the fact that the number of annual refractive procedures is increasing dramatically in most busy practices, I do not believe that most of these surgeons would let their cataract volume (which they have worked so hard to build) dwindle. No, I believe that there is a different culprit responsible for this decrease in volume, and it is called managed care!
Despite what insurance companies and health maintenance organizations represent to the public, managed care has had a dramatic effect on the way physicians practice medicine, and this effect is certainly no different for ophthalmologists. First, any eye surgeon who has been “capitated” for his or her services knows that they “lose” money any time they perform a procedure. Suddenly, the criteria for a “visually symptomatic” cataract changes, and surgeons (especially those in a group with a capitated contract) feel new pressures to decrease the number of surgeries that they perform. Although the capitation of specialists appears to be losing favor, even those health plans that do not capitate specialists have changed the way they perform utilization review. Criteria for performing procedures have become much more strict and now require referral slips, authorization numbers, chart re views by out-of-area specialists, and a whole host of other loopholes to jump through before the surgeon can perform the procedure. It is not uncommon to have to wait 4 to 6 weeks for permission to perform a procedure, and that is only if all the loops have been jumped through correctly. Otherwise, authorization can be “denied pending additional information” causing another 3 to 4 weeks delay.
Although managed care plays a larger role in some states than others, very few areas in the United States are unaffected and, in my opinion, the pressures of managed care exerted on ophthalmologists are responsible for the decrease in volume of cataract surgery seen in Dr. Leaming’s survey. In addition, I would be willing to bet that despite the increasing numbers of elderly patients, the number of cataract surgeries performed in the United States will either remain stable or continue to decrease until “managed care” disappears.
John H. Zeiter, MD, FACS
Stockton, Calif.
Bilateral cataract surgery
To the Editor:
With regard to Dr. Steve A. Arshinoff’s advice in Ocular Surgery News that he performs bilateral cataract surgery at the same sitting (“Bilateral cataract surgery can be safe, surgeon says,” 8/1/99 issue, page 9), I would draw his attention to firstly, the Hippocratic Oath where we all swear “to do no harm.” Secondly, to the obvious conclusion that if he performs enough surgery, he will eventually run into a case of endophthalmitis. Thirdly, after Dr. Arshinoff has his first bilateral endophthalmitis, I cannot think of one ophthalmologist who could defend him in a malpractice suit.
This paper brings to mind an anecdotal story of a Canadian ophthalmologist who removed the wrong eye in a patient who was scheduled for enucleation for malignant melanoma of the choroid. It is said that when he discovered his error, he committed suicide.
Dr. J. Bolgus’s remark supporting this program also makes no sense since firstly, those 500,000 patients are not all driving (there are busses and subways) and some would not drive because of poor vision. Those remaining would still be driving somewhere and probably get into the same accidents whether going to the doctor/hospital or to a shopping center.
Marvin L. Kwitko, MD, FRCS(C)
Montreal, Quebec
MEETH
To the Editor:
As an alumnus of the Manhattan Eye, Ear and Throat Hospital (MEETH) ophthalmology residency program, I have read in Ocular Surgery News with shock and dismay about the closing of the MEETH eye residency and the possible closing of the hospital (“Unmaking a world-class institution: the case of Manhattan Eye and Ear,” October 15, 1999 issue, page 89). The hospital administration appears to be completely out of touch with the realities of day to day delivery of health care, as well as the greater missions of a first class specialty care institution.
First, the board could have explored partnerships with either one of the local general hospitals or medical schools in terms of the residency program. There are plenty of precedents for a specialty hospital partnering with a larger general hospital or university program while maintaining its own board.
Second, the notion that a series of local clinics providing specialty care in ophthalmology without both a main center and without a residency to provide the treating physicians is ridiculous and ludicrous and shows just how out of touch the lay board is. Most of the direct care provided at the Harlem clinic was provided by the residents. The joint mission of providing both indigent care and a first class research and teaching institution can only occur if there is a “Mother Ship” as Dr. Dodick put it. And if the board believes that its only mission is to provide care to the indigent, then it is very “myopic” indeed, for indigent, middle class and wealthy all benefit from research in ophthalmology!
Third, the board could have easily transformed the facilities into a more modern type of delivery system by expanding the OR’s, closing inpatient beds, managing its finances better and changing the name of the institution from “Hospital” to “Center” or “Institute” to more accurately reflect the change in importance of the outpatient versus inpatient nature of the facility. Fourth, there are many “privately” funded fellowships in ophthalmology in which the fellow’s salary does not depend on Medicare direct funding. All that was lacking in the MEETH debacle was a board and CEO that was interested in closely working with the attending medical staff on a jointly beneficial project. Hopefully, the institution will survive.
Steven A. Gross, MD
St. Petersburg, Fla.