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March 2005


More Research Is Needed

Phacomania: A New Phenomenon?

More Research Is Needed

In “Finding a Place for the Ex-Press Shunt” (Clinical Update, October), I was particularly struck by the quotation of Robert D. Fechtner, MD, regarding the use of surgical steel as a material for ocular implantation. He correctly points out that we don’t know the long-term effects of implanting a steel object into the intraocular environment. The obvious question is why use this material at all?

Other options exist and they do not represent such an unknown. Silicone, acrylic and PMMA implants—unlike “implantable steel”—have been used in high volumes and these materials are known to be biocompatible within the eye. 

There is no long-term experience with steel implanted into human eyes for therapeutic purposes. None.

The words “implantable” and “steel” should not be used together when describing an ocular implant, regardless of the manufacturer’s claims.

What we know about stainless steel is that it contains iron. Foreign objects with iron cause ocular siderosis (which, ironically, may include glaucoma) and are removed from the eye. How is it that this axiom that every first-year eye resident learns is suddenly not relevant? 

There is a reason that no other ocular implant for any purpose is made of steel: At best its long-term effects are unknown, at worst it is potentially toxic. Do we really need to know anything else about the Ex-Press shunt? Not until its manufacturer recognizes what we do know about steel. 

Until then, its usage amounts to human experimentation, apparently and inexplicably, with the FDA’s approval.

Until the glaring issue of steel as a material for ocular implantation is addressed, the role of the Ex-Press shunt will remain an interesting idea that is unusable by the ethical ophthalmologist.

Steven A. Odrich, MD
New York

Phacomania: A New Phenomenon?

They always tell you how many cases they did in a day. It is a compulsion. You are supposed to be impressed. Six, seven or eight cases per hour. Each case perfect with no vitreous loss, 20/20+ vision, one day postop and a crystal clear cornea. They usually tie up two or three operating rooms and come in with a small army of support personnel to keep the flow going. They are truly gifted surgeons.

But what about the indications for cataract surgery? Does anyone ask the patient about their visual needs or how much trouble they are having? I’ll bet not. The indications for surgery must be loose. The technician gets the glare meter out and tells patients how poor their vision is and how bad the numbers are.

“But I seem to see pretty well and am not really having a problem, other than occasional difficulty seeing the golf ball.” The retiree is unable to see a golf ball at 100 yards and would benefit from cataract surgery. Why deny this geezer the only pleasure in life that he has left? “I must be seeing a whole lot worse than I thought—guess I better get these cataracts out.”

So this is what cataract surgery has come to. The surgeon will do the most cases possible and let the system absorb the cost. Occasionally, the patient shows up to the operating room and hadn’t seen the surgeon preoperatively. They are slowly killing the goose that lays the golden egg, ruining the system for those who do not practice that way.

The cataract surgery decision is—99.8 percent of the time—made by the patient. They decide how much trouble they are having in their life, not the technician or ophthalmologist.

A conscientious ophthalmologist will actively listen to the patient and help with the decision. You do not need 20/20 vision in each eye to “get through the gates.”

Phacomania is a form of slow insanity practiced by an ever-increasing number of ophthalmologists who don’t want to deny the world their surgical talents.

Judson P. Smith, MD
Fort Worth, Texas

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