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March 2011

Surgical Innovation How to Strike the Right Balance?
By Richard P. Mills, MD, MPH, Chief Medical Editor, Eyenet
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As I was reviewing this month’s feature story on new glaucoma procedures and devices, I found myself in an internal tug-of-war. On the one hand, these new innovations provide potential substitutes for trabeculectomy, the operation glaucoma specialists love to hate, even while performing it regularly. On the other hand, the new surgeries may waste valuable patient time and social resources on an ultimately ineffective procedure, with trabeculectomy or a glaucoma drainage tube being required in the end.

I was reminded of a concept popularized in the United Kingdom about a decade ago. Gynecologist J. W. Scott conceived a model to illustrate the cyclical rise and fall of a surgical technique. Despite showing only minimal mathematical resemblance to its namesake, Scott’s “parabola” (see PDF) portrays the life cycle of a new concept—displaying initial encouraging results, widespread adoption, unacceptable complications, then disuse. Within ophthalmology, the late Robert N. Shaffer, MD, used to tell his fellows and residents, “we better use [the new procedure] now while it still works 100 percent of the time and has no complications!”

Yet we are all aware of past innovations that have stood the test of time, despite initial criticism: the intraocular lens, phacoemulsification, perhaps endothelial keratoplasty. Without initial enthusiasm, and professional advocates, new innovations risk being lost in the cacophony of voices vying for our attention. Some of my colleagues argue that industry funding will disappear from glaucoma without our professional advocacy of new devices. At meetings, attendance soars when innovators take the podium, even though they may have changed their minds from what they said last year.

So where is the happy medium? When should we embrace innovation and when should our skepticism reign? In an era of scarce health care resources, should we smother innovation by requiring a substantial evidence base before reimbursement is allowed? Or should we allow payment during a trial period, during which a new device or procedure can prove itself? This column may be entitled “Opinion,” but this time I’m ashamed to admit I haven’t one to offer.

Dr. Mills is chief medical editor of EyeNet.


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