Viewpoint FROM THE CHIEF MEDICAL EDITOR

Keep it Simple

Larry E. Patterson, M.D.

"Simplicity means the achievement of maximum effect with minimum means." — Dr. Koichi Kawana, Architect

"Less is more." — Ludwig Mies van der Rohe

In a world that has become progressively more complicated, it's refreshing now and then to step back and simplify some aspect of your life. One obvious example of simplification lies in our number-one surgery, cataract extraction. While this process has changed dramatically over the last century, I was thinking of the changes just in the last decade or two of my short career.

A few years ago I presented a lecture at a meeting in Rome, and struggled to come up with a topic that would be of interest to my Italian colleagues. The title ended up being "Forceps-Free Cataract Surgery." I had come to realize that, over the last decade, I had all but abandoned the use of forceps during cataract surgery. The side-port incision was made with a dull-sided diamond knife which fixated the globe while the main incision was made, as described years ago by Bruce Wallace. I injected the lens into the eye by gently rotating the cartridge tip into the wound. And since we'd gone sutureless since the 1990s, the final need for forceps was obviated.

So, where else did the operation become simpler? We slowly transitioned from regional injection anesthesia to topical. I remember this being quite frightening at first, but quickly found topical anesthesia becoming the norm. Today, I do a block less than one percent of the time.

Originally, we supplemented topical cases with intracameral lidocaine and I.V. sedation. After hearing a talk by Mark Blecher, I came to agree that most patients did just as well without the intracameral lidocaine, especially now with topical viscous tetracaine. To make things even simpler, a large study showed that maybe even the I.V. was unnecessary. For about the last five years, we've started an I.V. less than five percent of the time, with no regrets.

Finally, I heard a talk a few years ago by Richard Lindstrom in which he discussed simplifying the postoperative protocol. Now we see most routine patients at one day and two weeks. We found almost all refractions were quite stable at two weeks, comparing them to the next measurements at the six-month post-op visit. Of course, only a highly trained athlete such as Michael Jordan could make playing basketball look easy. While we've reduced the complexity of most routine cases, the skill required has, if anything, increased, while the margin of error has dramatically decreased.

Why go into all this discussion about simplification? I don't do this often, but you'll just have to stay tuned for next month's column when I bring this all home, tying our practices, the economy and your happiness together in one neat bundle. Until then, I share with you the words of one much wiser than me: "Make everything as simple as possible, but not simpler." — Albert Einstein