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November/December 2004



Better Than a Vuitton

Just Ask Them

The article “Endophthalmitis: Cataract Controversy” (June) reviewed evidence implicating clear corneal cataract incisions with a higher incidence of postcataract surgery endophthalmitis. It failed to reference a study, “Bacterial endophthalmitis after small-incision cataract surgery: Effect of incision placement and intraocular lens type” by Nagaki et al. (J Cataract Refract Surg 2003;29:20–26).

This study prospectively looked at 7,622 patients (12,317 eyes) comparing a temporal clear corneal incision to a superotemporal sclerocorneal incision and found the relative risk of culture-proven endophthalmitis to be 4.6 times less in eyes with a scleral tunnel incision compared with eyes with a clear corneal incision. The incidence of endophthalmitis in eyes with a scleral incision was 0.05 percent and in eyes with a clear corneal incision was 0.29 percent.

In this era of evidence-based medicine, surgeons who prefer clear corneal incisions should perform a study in hopes of demonstrating at least equal safety between clear corneal incisions and scleral tunnel incisions.

As more evidence linking clear corneal incisions with postcataract surgery endophthalmitis becomes available, surgeons may wish to rethink the article’s concluding quote: “The real message is not that clear corneal incisions are inherently risky, but rather that there’s less margin for error. They must be properly sized and constructed.” Doesn’t “less margin for error” mean more “risky”?

Nancy M. Holekamp, MD
St. Louis

Better Than a Vuitton
One really does use the meeting bags long after the meeting. This is the interior of my HUMMV in Iraq, ready for patrol. Notice how the bag sits on top of the flack vest.

Col. Brian T. Nolan, MD, FACS
Lexington, Ky.

A veteran of the 2000 Annual Meeting reports for duty.
Caption: A veteran of the 2000 Annual Meeting reports for duty.

Just Ask Them
I was delighted to see “Beyond the Snellen Chart” (July/August). It quotes Wiley A. Chambers, MD, as saying, “We don’t have very good instruments . . . we don’t have good measures of quality of life.” I believe he is referring to the standard measures of quality of life—some are important contributions, such as the VFQ-25 developed by the NEI. However, Dr. Chambers’ comment is welcome—these instruments do have marked limitations. They are attempts to quantitate information, which is important in performing science. However, no standardized approach will ever allow the uniqueness of patients to be appreciated appropriately.

Fortunately for patients, there is a valid way of obtaining this information, specifically, taking a good history. Unfortunately, the art of history-taking has been increasingly lost as physicians have come to rely more on standardized tests and as reimbursements have been based more on obtaining standardized amounts of standardized information.

Every physician today is challenged with checking the right number of boxes on the patient’s chart. But the art of medicine is involved in knowing that you have to ignore most of the boxes and concentrate on what is quintessential to the patient. Asking the question “How are you?” in a way that shows that you really want to know the answer requires the ability to phrase the question and use the proper body language to allow the patient the greatest chance of answering meaningfully. 

The best way to understand a patient’s quality of life is to ask about it. Although such information may not be used in a standardized study, when history-taking is done by a knowledgeable person in a caring, compassionate and comprehensive way, the information obtained can help assure the patient obtains the best care possible.

George L. Spaeth, MD

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