Brighter and better
In her shortlisted essay for the 2018 John Henahan Prize, Dr Jacintha Gong says research helps ophthalmologists objectively discern what to preserve, and what to discard
Some years back, an elderly gentleman was on my cataract surgery list. As I prepared to operate, he remarked, “I should savour these last moments of looking through my natural lens; I’ve had it for 90 years! Tomorrow should be a change – all brighter and better?”
There was a time when there was no treatment for cataracts. Once, someone who lived to develop cataracts had as little hope for a cure as someone today with palliative disease. Desperate patients were willing to undergo even risky, unproven procedures to preserve or restore their eyesight. Primitive methods of cataract removal, like couching, are now ridiculed by present-day cataract surgeons, who enjoy good results with standard phacoemulsification.
Have we become complacent, as we consider how cataract surgery has progressed in the last century? Major advances, like the implantation of intraocular lenses, have largely been due to serendipity rather than concerted research. We know that fortuitous happenstance and expert opinion are not sufficient evidence upon which to base clinical practice. High-quality research is the cornerstone of safe, modern medicine. If nothing is present in the current literature on a certain topic, any practice is theoretically defensible.
Do we need to critically re-appraise cataract surgery, or have we, like my patient, gotten so used to doing and perceiving things in a certain way for years, through a flawed lens of surgical inertia and reliance on historical innovations? Do we need more robust evidence, like randomised controlled clinical trials (RCCTs) in cataract surgery?
Let us consider when RCCTs may be useful. A common misconception is that RCCTs are only required if a standard of care needs revision, or treatment is of untested benefit. By contrast, cataract surgery is fundamentally an elective procedure, that is voluntarily chosen by patients who have often heard of success stories. Does a procedure that is so universally accepted as beneficial, by both clinicians and the general public, have room for improvement? Even if it did, it could be unethical and difficult to recruit patients for such a study.
RCCTs exist to identify a cause-effect relationship between a proposed treatment, and the outcome. What aspects of cataract surgery are amenable to analysis by RCCTs? Whilst RCCTs do exist about the steps in cataract surgery (for example, the use of intracameral antibiotics in preventing endophthalmitis), there are inherent barriers to performing RCCTs in the method and tools of cataract surgery. Part of the problem lies in the practicalities of randomisation and blinding, standardising of surgical technique and skill, and measurement of subjective outcomes. Like many other surgeries, there is a paucity of RCCTs in cataract surgery. Traditionally, surgeons are quick to adopt intuitive methods of operating, some of which are learnt from mentors and not necessarily supported by rigorous evidence. Also, large RCCTs are expensive to fund and may be infeasible to conduct in a private practice setting, where surgical reputation could compromise on impartiality, and patient numbers are generally fewer.
Given the challenges and accepted benefits of RCCTs, we tend to react in two ways. Firstly, we memorise landmark trials, on the perilous assumption that their findings are still applicable decades later. It is important to critically appraise RCCTs in cataract surgery, in line with other up-to-date RCCTs. Has antibiotic resistance changed? If so, our RCCTs may need to be repeated. Secondly, we may neglect to undertake and support other forms of research like cohort studies, to our own disadvantage. Poorly conducted RCCTs are potentially more harmful than no RCCTs, and RCCTs should not be considered as the only method of legitimate research.
Research, whether in the form of RCCTs or other well-designed studies, is imperative if we wish to achieve progress and precision in our practice in the 21st Century. It should not solely be commercially driven, and it should not be viewed with apathy, cynicism or pessimism. How else will we know if what we do is beneficent and non-maleficent? We know that some of the things we do today will be frowned upon, in future generations. Conversely, some procedures that were perceived as outrageous are now common practice. Research helps us objectively discern what to preserve, and what to discard.
The essence of ophthalmic research reflects the heart of the cataract surgeon – to improve safety and sight for all our patients. Like my venerable patient, we are grateful for past vision but are not blind to its shortcomings. Instead, we embrace new insights, born of cutting-edge investigative research. Tomorrow should be a change – all brighter and better.
Dr Jacintha Gong is a trainee in the Ophthalmology Department, NHS Tayside, UK