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Up Front | Sep 2008

Controversies Versus Personal Preference

This issue discusses several controversial topics in cataract and refractive surgery. As Chief Medical Editor of CRST Europe, I have a responsibility to remain objective and impartial; however as an ophthalmologist (like our readers and authors, to whom we are immensely grateful) working in the best interests of my patients, I have my preferences (or would that be bias?). Allow me the liberty of discussing a couple of controversies.

Endophthalmitis prophylaxis remains controversial, and this is one area I find baffling. Criticisms have been levied against the ESCRS study1 for evaluating a commercially unavailable drug. More specifically, some surgeons question the risk of toxic anterior segment syndrome (TASS) as a result of surgeon/nurse preparation of cefuroxime, the unexpected high risk of endophthalmitis in the noncefuroxime arms of the study, and the exclusion of the mouth-watering albeit pricey fourth-generation fluoroquinolones.

The ESCRS study did demonstrate a higher risk of endophthalmitis after construction of a clear corneal incision (which I abandoned in 1998 after auditing hospital data where the only cases of endophthalmitis had clear corneal incisions). The study also showed the value of cefuroxime and substantiated the Swedish experience.2 Although randomized, controlled trials are an excellent method of evaluation, an alteration in prevalence after instituting a change can provide useful practical information.

As a visiting consultant to the Comprehensive Community-Based Rehabilitation in Tanzania (CCBRT) Disability Hospital, I experienced a case of endophthalmitis after small-incision cataract extraction. I influenced the introduction of cefuroxime at the institution, and since then, 21,000 consecutive cases in just over 3 years have been without endophthalmitis—a considerable change from one case every 3 weeks. One single intervention resulted in a major change, and we felt this deserved a letter to the Journal of Cataract and Refractive Surgery.3 Just like many of my UK colleagues, I use intracameral cefuroxime prepared by a licensed pharmacy. To date, I have not seen a single case of TASS.

So the next controversial topic: What lens is best? Arguments for different IOLs will continue to be a prevalent topic of discussion among cataract and refractive surgeons. European ophthalmologists have access to many IOLs not currently available in the United States. I have and will continue to use a variety of IOLs, including the Eyeonics Crystalens (Bausch & Lomb, Rochester, New York), Restor (Alcon Laboratories, Inc., Fort Worth, Texas), Acri.Tec Acri.LISA (Carl Zeiss Meditec AG, Jena, Germany), and the Tecnis Multifocal (Advanced Medical Optics, Inc., Santa Ana, California). Like my fellow colleagues, I base my preferences partially on objective criteria but also on patient reaction.

Now for my unbiased stance: I tend to agree with Frank A. Bucci Jr., MD, of Pennsylvania, about his experience with the Tecnis Multifocal; however, I prefer an alternative lens, the Acri.Tec Acri.LISA, which is readily available in Europe. Like the Tecnis, it is aspheric, diffractive, uncompromising in terms of near vision based on ambient light, and is now becoming available as a toric multifocal. Best of all, I can implant this lens through a 1.8-mm incision. The Crystalens, in its new incarnation, is also an excellent alternative and fairly forgiving. Like I. Howard Fine, MD, of Oregon, we also found better outcomes in myopes in more than 100 cases. The thinness of the lens might make the implant easy to bend or arc and thus provide the plus power. One must not forget that myopes have a greater depth of field, and their conoid of Sturm is narrower because of a longer axial length as a result. Myopic eyes are also more forgiving than hyperopic eyes, an observation in both lens-based and corneal refractive surgery.

Are controversies anything more than preferences based on personal experience and rationale? This issue provides yet another excellent array of articles likely to pique interest and further fuel controversy. We welcome your views, which we shall be glad to publish.

Dr. Daya states that he is an investigator for Carl Zeiss Meditec AG/Acri.Tec and Bausch & Lomb/Eyeonics.