As I See It

Lamenting the loss of true scientific discourse

We must keep in mind that the course of medical progress has never run smoothly.

By Paul S. Koch, MD, Editor Emeritus

As I speak with people concerning laser-assisted cataract surgery, I am impressed by the degree of emotion attached to the discussion. I know some who, oddly enough, seem personally offended by the whole idea. I’ve been around long enough to have seen this reaction before, either with techniques that became the standard of care or that slipped into obscurity.

It appears some of us come to meetings or read papers from the perspective of an opinion already formed, “LACS is bad”, and are looking for data to support the opinion “See, I was right!”, as opposed to gathering information to help form an opinion. If so, that may be a sad reflection on the impact modern news channels have on us — first cement a position, then accept only news supporting that position and disregard all that are contrary.

In praise of the scientific method

In the past we started with the position that existing methods worked well. New methods challenged our orthodoxy and were naturally met with skepticism. Our debates about the new method might last for years before resolution. First we would hear the good points, then the bad ones, then both again until we hashed out a consensus.

Recall previous controversies such as the intraocular lens (“The intraocular time bomb”); extracapsular surgery (“Why leave in part of the cataract?”); phacoemulsification (“You still have to enlarge the incision for the lens”); corneal refractive surgery (“Surgery when there is no disease?”).

In each case we reported, debated, read and analyzed data before reaching a conclusion in favor of each. As we were doing that, we had to keep up with a moving target as implants moved from the pupil to the capsule, phaco from the anterior chamber without viscoelastics to the bag with them and radial keratotomy to LASIK. The original proposal either developed into a successful product, or disappeared.

Inquiry takes time

Younger surgeons may not realize the long years each discussion lasted before a conclusion was reached. Today positions apparently become entrenched without such scrutiny. An acquaintance recently told me he was firmly against a procedure because he read a paper against it. A paper? Just one?

Let us remember that phase one of any development does not necessarily reflect where that adventure will take us. We did not throw out phacoemulsification when we saw corneal edema; we found ways to avoid it. We did not throw out IOLs because of the UGH [uveitis-glaucoma-hyphema] Syndrome; we learned to make better lenses. We did not discard refractive surgery when we saw progressive hyperopia; we learned a different way to reshape the cornea.

The current debate is laser-assisted cataract surgery. I happen to lean towards “Aye” at this time, and some of my good friends would vote “Nay”. But we all understand that we are at phase one and we have years to go to maturity. There is much to learn. Opinions will change.

If I am right and the Aye’s eventually have it I know there will remain those who will be stubborn in their lack of favor. Some will be surgeons opposed to the laser but others will be phaco salesmen who want to keep selling machines. If so, that would be completely understandable. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, RI. His email is pskoch@clarisvision.com.