Random Thoughts from a Restless Mind

Dr. Darrell White's Personal Blog

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Posts Tagged ‘Implant’

The Surgeon Has No Clothes

I stand by the side of the road, wide-eyed in amazement, alone despite the fact that I am surrounded by other spectators. We are watching a parade, a great spectacle to celebrate the apparent dawning of a new age in cataract surgery. One after the other they pass me, the great and famous experts, the Emperors of ophthalmology. Each one sits upon a throne surrounded by bags filled with the coin of the land, the thrones built upon the newest fashion, a femtosecond cataract laser. The rest of the crowd is dazzled; they stand in silent awe as these men with such magnificent reputations usher into the kingdom the latest fashion.

I blink once. Twice. I cannot believe what I am seeing.

Over the millennia there have been thus far three truly revolutionary advances in cataract surgery (a cataract is a clouding of the natural lens in our eye). The ancient Egyptians, and for all we know Ancients of many other sorts, “cured” cataracts through a procedure known as COUCHING. Using a thin bamboo reed the “surgeon” punctured the eye and simply pushed the opaque lens into the gel–filled open cavity in the middle of the eye. Not terribly elegant, but if the eye did not become infected it actually dramatically improved vision in the days of the Pharaohs. This was the original cataract surgery.

The advent of very fine suture material and magnifying glasses brought with it the development of intracapsular cataract surgery. The eye was entered through a large sterile surgical incision and the cataract was removed as a whole. After the incision was closed with these rudimentary sutures it was necessary for a patient to remain stationary, her head held still by sandbags for a week. As barbaric as this sounds today, this procedure, along with cataract glasses, dramatically improved both the safety and the visual results of cataract surgery. Revolutionary change number 1.

Intracapsular cataract surgery was followed by extracapsular cataract surgery, the procedure made necessary by the creation of intraocular lenses. These tiny implants, less than half the size of a dime, are implanted in the capsular bag left behind after the inner workings of the cataractous lens had been removed; think of it as filling an empty grape skin. Better vision, greater safety, and with the addition of mechanical assistance extracapsular cataract surgery also brought efficiency and speed to cataract surgery. Clearly superior, the extracap supplanted the intracap, and during a time of transition both procedures received identical financial coverage from all forms of health insurance. Revolution number 2.

What followed next in ophthalmology was probably the predecessor of all that we have come to know about the intersection between commerce and care in American medicine. A certified genius who was so sure that he was right that he simply did not care what any of his colleagues– indeed what any ophthalmologist at all–thought about him or his invention, introduced  phacoemulsification. Charles Kelman discovered that you could remove a cataract of any size through an extremely small incision by first dissolving it inside the eye with high–frequency ultrasound. Kelman was initially viewed as a heretic, and early adopters of phaco technology were scorned by the ophthalmic orthodoxy. In response they marketed phacoemulsification as the superior procedure that it was, further enraging the establishment by becoming wealthy and famous through the efficiency and efficacy of this surgical revolution.

Once again, during the time of transition from extracapsular cataract surgery to phacoemulsification, both procedures were treated equally in the eyes of health insurance, and every patient’s surgery was paid equally with either technique. Revolution number 3.

As phacoemulsification gradually ushered extracapsular surgery into extinction in the 1980′s there began an era of relative tranquility in the world of cataract surgeons. There was very little to distinguish one surgeon from another save for gross incompetence, a complication rate so far outside the norm that it could not be ignored. How could this be, you ask? Well, all of the intraocular lens implants during the initial part of this era were essentially the same. Each lens development, each evolutionary step however big or small, was quickly adopted by the overwhelming majority of surgeons, and pretty much every cataract surgery patient received a state–of–of the–art implant for her surgery. The SURGEONS surely knew who among them was better. They knew who was faster, slicker, more elegant, and dramatically less likely to have any complications whatsoever. But even the most astute patient was incapable of knowing the difference between a 20-minute cataract surgery and a five-minute cataract surgery, one plodding and clumsy, the other elegant and quick, so powerful was this new technology. Every cataract surgeon in America could, and did, look their patients in the eye and say their outcomes were essentially the same as every other surgeon; they, themselves, were just as good as every other cataract surgeon.

This happy time of peace, love, and tranquility came to a screeching halt in 2003 with the introduction of an implant called the Crystalens. Here, for the first time, the cataract surgeon was able to give his patient excellent vision at any and all distances WITHOUT WEARING GLASSES. The problem, though, was that the Crystalens was actually rather tricky to insert. You really DID need to be more equal then your surgeon peers in order to get this extraordinary outcome. Not only that, but the implant was almost 10 times as expensive as what now became known as standard implants, it required roughly 3 times as much work preoperatively and postoperatively to achieve this outcome, and all of a sudden there was a very clear division between cataract surgeons. There were those who did what became known as premium surgery because they could, and there were those who didn’t.

Surgeon Emperor’s rode on their thrones through the throngs of what once were their peers, adorned with wondrous capes and crowns they so deservedly wore for they were truly better surgeons, and they were paid more to do this premium surgery. For you see, a great change had occurred:  the health insurance companies did NOT view these new implants as equal to those in present use, and in their wisdom they allowed patients to pay with their own money for these more expensive lenses. This they did, though not in great numbers, just enough that it started to become clear that some surgeons were more equal than others. This was not a true revolution in cataract surgery itself, only the economics of cataract surgery.

So here I find myself, one of these Lesser Surgeon Emperors of the premium implant era. I stand among the crowd as this very small group of self–proclaimed Greater Emperors glide by, pulled along on their grand femtosecond chariots. They are declaring, loudly and to anyone who’ll listen, that laser cataract surgery is the fourth great revolution in the long history of cataract surgery. “It’s more accurate,” they declare. “It will make cataract surgery safer!” They cry. “It’s the next, mandatory step in premium cataract surgery. It’s well–worth every penny of the additional $1000 the premium cataract patient will pay,” they state as they preen on their perches.

I blink as I stand there. Something’s not quite right. The rest of the crowd cheers these magnificent creatures but still something seems wrong. A better, more accurate and uniform capsulorhexis (the initial opening into the cataract)? That doesn’t seem to be a problem with premium cataract implant surgery today, at least in the hands of the best surgeons. Better sealing wounds to decrease the number of post–operative infections? Again, the busiest, highest volume, best cataract surgeons already have the lowest infection rates in America. A simpler, more reproducible and accurate limbal relaxing incision (a technique to treat astigmatism)? Well, I HAVE heard that an inability or unwillingness to handle astigmatism IS a barrier to implanting premium cataract implants, but that doesn’t really seem to be much of a problem for those surgeons who are successfully using them now.

I blink once again and then it hits me: the Emperor Surgeons have no clothes! They are parading right in front of us, declaring the femtosecond laser the proverbial silk purse to be utilized as part of a premium service, carried only by those cloaked in the finery of the court as they have been told by the industry courtesans.  Femptosecond laser cataract surgery is a revolutionary step, but it is a premium service like the Crystalens, and is properly utilized only by Emperors.

They are right but they are also so very wrong.

Blinded by the hype, blinded by the glow of their reputations, by the industry courtesans as they wave their empty clothes hangars, the naked Surgeon Emperors are trying to MISS the fourth great revolution in cataract surgery, because femtosecond cataract surgery is not a silk purse, it’s actually just a better backpack! Femtosecond laser cataract surgery is the technology that reestablishes real equality among cataract surgeons. It is not the scepter of the Greater Surgeon Emperor, it is rather the butter knife of the common surgeon.

Think about it. The best cataract surgeons in America are not having any difficulty making a proper capsulorhexis, and they are obtaining over–the–top outstanding outcomes with literally every single type of intraocular lens available. These are not the men and women who are having outbreaks of endophthalmitis (a total eye infection) because of poor technique creating their incisions. We are not seeing an epidemic of untreated astigmatism in the population served by these extraordinarily talented surgeons, especially in those eyes that have received a Crystalens or other premium lens implant. The femtosecond laser as a necessary, mandatory tool to improve the outcomes in THIS group of surgeons performing premium service cataract surgery? Please. The incremental improvement in outcomes will be infinitesimally small in this group, and I will go out on a limb and say that any of the Emperor Surgeons in the parade who are truly among this group of noted surgeons would tell you just this.

No, femtosecond laser cataract surgery is the next great revolution in regular, garden-variety, standard implant cataract surgery performed by the middle–of–the–Bell Curve cataract surgeon. Here is a quick story to illustrate my point. An 80-year-old man had cataract surgery performed in his right eye by one of the most deservedly famous cataract surgeons in the United States. Perfect incision. Perfect capsulorhexis. Limbal relaxing incisions that reduced astigmatism to 0. Every single aspect of the operation that would have been impacted by the femtosecond laser was performed flawlessly. The outcome? Not so great, actually. The patient had a poorly positioned implant causing blurred vision, which was not discovered for approximately 9 months due to postoperative inattention. This caused him to be greatly unhappy with his result and ultimately causing him to seek another surgeon for his left eye even after the blur was fixed.

This new surgeon simply could not be more different from the world famous surgeon. A very kind and gentle soul with a lovely and caring bedside manner, he was at best deeply buried in the middle of the surgical Bell Curve. The outcome? Not so great, actually. A poorly done capsulorhexis prompted him to default to a much older lens implant, a clear technological backward step, and a surgical problem that would clearly be prevented with the use of the femtosecond laser.

So my friends, the femtosecond laser actually IS the fourth great revolution in cataract surgery, but the Greater Surgeon Emperors are failing to see that, like intracapsular to extracapsular, and extracapsular to phacoemulsification, phaco to femtosecond is a revolution for the masses. The femtosecond laser will make an average cataract surgeon a good one, a good cataract surgeon a very good one, and a very good cataract surgeon potentially a great one. It will do very little for the outcomes of the already great cataract surgeon. Oh, there may certainly come some new type of implant where the outstanding surgeon will require a femtosecond laser in order to properly use it, but as of this moment that particular widget doesn’t exist. The femtosecond laser is a technology looking for a use, an investment looking for a market. Will it find its place only with the Emperors, those who should be leading, now instead just riding behind?

The greatest of Emperors lead.  If I am right, if this is actually a technology which will make regular cataract surgery safer and more predictable, Surgeon Emperors and their industry minions should be pounding the streets of Washington to make this fourth revolution just like its predecessor: available to all. They should call it as it is, the average surgeon’s pathway to greatness. They should lead on behalf of every 80-year-old man who deserves a perfect capsulorhexis and a perfectly created wound to go along with his most modern standard implant. They should lead their surgeon brethren on behalf of their people. The greatest among these Emperor Surgeons will see nothing that is negative happen to them if they fight to make femtosecond laser cataract surgery just the next revolution in every day cataract surgery.

I blink. I wait for one of these Emperors to put on some clothes, get out in front, and lead.