As good as it gets?
In his shortlisted essay for the 2018 John Henahan Writing Prize, Dr Khayam Naderi says randomised controlled trials allow ophthalmologists to reflect on existing practices and consider potentially superior methods
The butterflies always start the evening before. Following a gruelling game of tennis to close my weekend, I stroll out of the courts for the journey home when the familiar feeling of anticipation for the morning ahead takes hold. For tomorrow morning is my weekly cataract list.
And despite entering my third year of ophthalmic training the exhilaration is yet to diminish, instead evolving from anxiety-heavy ambivalence to increasing elation and a growing sense of expectation as I continue to build on my skills as an ophthalmic surgeon. I will never forget the sense of achievement after my first completed case, nor the congratulatory handshake from my proud supervising consultant at the time. In fact, at the start of my training I considered myself to be a more ‘medically orientated’ ophthalmologist, as I greatly enjoyed the array of fascinating cases encountered in clinic. But as I gained more surgical experience and expertise, this notion has certainly been challenged as I strive to grow into my dual roles as both clinician and surgeon. It is fair to say that like many ophthalmology trainees my weekly cataract list is one of the highlights of my week.
AS GOOD AS IT GETS?
Going back to medical school statistics lectures, I recall how randomised controlled clinical trials (RCTs) were introduced as the absolute pinnacle of evidence-based medicine (despite their respective limitations), which continues to shape both medical and surgical practice. The current significance of RCTs in cataract surgery today, however, may be less obvious.
It is almost tempting to present the argument that in the developed world cataract surgery is already being practised to a very high standard. Advancements in surgical techniques and equipment have led to positive visual outcomes and low complication rates. Hence, the old adage: why fix something that is not broken? Furthermore, it can also be argued that perhaps research resources can instead be directed elsewhere, such as in progressive sight-threatening conditions such as wet age-related macular degeneration and glaucoma. Therefore, do we actually need a randomised controlled clinical trial in cataract surgery?
A MATTER OF PERSPECTIVE
The advances in medicine over the last century have been staggering, with further developments and breakthroughs continuing to come thick and fast. As doctors we aspire to build on our existing knowledge in order to provide the best available care for our patients. Cataract is a leading cause of reversible blindness worldwide and with a growing elderly population at our doorstep the demand for cataract surgery will continue. As mentioned, cataract surgery is already being practised to a high level. However, due to the complexities of such an intricate operation, where a host of patient and surgical factors come in to play to determine the final outcome, it can be argued that there is always room for improvement.
One of the first nuggets of wisdom I received at the start of my training was to “respect each case – no two cataracts are the same”. And from personal experience I can testify that encountering one floppy iris does not mean that you have seen them all! The potential for marginal gains in cataract surgery can lead to additional fine-tuning of an important operation, with further room for trials on a plethora of factors, ranging from surgical techniques to the choice of intraocular lens. Aspiring for perfection rather than resting on our laurels to meet ever-growing patient expectations.
Indeed, incorporating any potential changes into our daily practise to improve patient care requires reliable, statistically significant evidence. As doctors we all have to critically appraise any study findings put forward to us. And RCTs are the highest level of research study design to show us that there may be different or indeed totally new approaches that can allow us to progress. Providing of course, we are satisfied with the evidence on offer! In this regard, it is also important to note that we do not undermine the respective merits of other research methods such as cohort studies and case series, which are of value in their own right.
Undergoing cataract surgery is common and is now almost a rite of passage. The evidence provided by randomised controlled trials allows us to reflect on our existing practise and consider potentially superior methods of performing cataract surgery. In turn, we will continue to strive for the highest standards of care and minimise the risk posed to our patients who, along with their consent, have given us their trust.
Dr Khayam Naderi is a third year trainee at Broomfield Hospital, Chelmsford, UK