Viewpoint FROM THE CHIEF MEDICAL EDITOR

Second-Guessing a Fellow Surgeon

Larry E. Patterson, M.D.

We all have certain beliefs about a number of ophthalmic issues. I'd like to share a few of mine with you, unrelated though they may seem to be initially.

1. People with only one good seeing eye should wear glasses most of their waking hours for protection from injury. I was taught this in residency. Do they still teach this? It makes sense. Most of us have a spare eye in the event of an accident, but the person with only one eye has no backup.

2. By the same token, people with only one good seeing eye should strongly be discouraged from wearing contact lenses or refractive surgery. For one, we've introduced a small but real risk to their only good eye. Second, see number one! I know there might be some occasional unusual circumstance where someone occasionally needs to be able to see without correction (an actor for example), but it's the exception, not the rule.

3. You should avoid multifocal implants in someone who has significant ocular pathology such as amblyopia, macular degeneration, corneal scarring, etc. Your patient is paying extra out-of-pocket money for an enhanced result. Again, with rare exception, you want to avoid disappointment in these patients. Plus, these folks need all the contrast sensitivity they can get.

4. If you use a premium implant, you need a premium postoperative refractive result. That means no significant astigmatism, and the sphere should be very close to your target.

So, imagine my reaction when the following patient came to me for advice. A very nice man in his late 70s presented with a history of a prosthesis after enucleation following a knife injury as a child. His fellow eye had a lifelong history of less than perfect vision, presumably from amblyopia. Our examination of that fellow eye revealed 2 diopters of cylinder, mild macular degeneration, and a multifocal posterior chamber lens implant. His uncorrected vision was 20/60 at distance, J8 at near. His best corrected vision was 20/40 at distance, J3 at near.

I'm trying to be fair to the surgeon. Perhaps the cataract was too dense preoperatively to detect the macular changes. Perhaps the patient failed to mention the history of poor vision in that eye. But this doesn't help my conundrum with items 1 and 2 above.

Does this scenario bother you? Does anyone have any advice as to what to say to this patient who is very unhappy about his outcome, especially since he paid a lot of money out of pocket for a premium lens? Would any of you do anything for him, outside of prescribing prescription spectacles to help him see better and to protect his only remaining eye?

I'd appreciate your thoughts, especially from those in academia who are teaching our future eye surgeons.