Healthy Controversy is a positive step in ensuring progress; it compels ophthalmologists to critically assess and refine their performance, enables innovators to come up with newer ideas and stimulate research to circumvent any controversial approach that may currently exist.
As ophthalmic science continues to progress, a multitude of diagnostic and treatment options now exist. Each may work in a given setting, and the choice rests with the surgeon depending on several factors such as novelty, familiarity, availability, scientific basis and lastly, cost. Controversy inevitably arises as to the ‘best’ intervention available.
This issue discusses several such “Controversies”.
The use of intracameral antibiotics is steadily rising amongst cataract surgeons worldwide. It has the definite promise of reducing risk of endophthalmitis1, yet there are several concerns that need to be addressed. Most intracameral antibiotics are not available as a commercial preparation, and issues related to pharmacy compounding and dilution errors surface from time to time. Intracameral cefuroxime is not available as a commercial preparation, except for a few countries. Meanwhile, the emergence of Haemorrhagic Occlusive Retinal Vasculitis (HORV), a visually devastating complication, raises serious questions on the safety of intracameral vancomycin. Moxifloxacin, a fourth generation fluoroquinolone, appears to be safe and effective so far. Personally I have been using intracameral antibiotics for a long time, and have shifted from vancomycin to intracameral moxifloxacin for the last 9 years.
The use of intracameral antibiotics will certainly be adopted by many more, but we hope that we can get safer, more efficacious and easier – to – use preparations in the future.
Immediately Sequential Bilateral Cataract Surgery has always been a matter of great controversy. Proponents of this approach cite its convenience and cost-effectivity, which may be true for some Western countries but may not be relevant to other parts of the world. Endophthalmitis remains a major safety concern and, in many parts of the world, we are still striving to achieve consistency in meeting target refraction and visual outcomes. It seems logical to assess the technical, functional and refractive outcome in one eye to give us a chance to modify the surgical plan/technique for the other eye. Having said that, there are few select situations, such as those who need administration of general anesthesia or have high-risk systemic features in which immediate sequential bilateral cataract surgery certainly has a role. Nevertheless, for the population at large, delaying the second eye surgery at least by a few weeks seems to be the preference.
Astigmatism correction at the time of surgery is becoming an integral part of cataract management. Toric IOLs have been a game changer of sorts here. Compared to other options such as LRIs, incisional methods and laser refractive surgery, they seem to offer more predictable and precise outcomes. Moreover, it is a part of routine cataract surgical procedure and does not involve learning additional skills or instrumentation for the surgeon.
Finally, the frontier of refractive surgery is an exciting, fast progressing one. Modern – era LASIK has become one of the safest and most effective eye surgeries. And yet, there is a long way to go in terms of enhancing visual quality and reducing risks of side effects such as dry eyes and ectasia. Newer treatment paradigms such as topography-guided procedures bring the hope of offering better visual qualities to a wider group of patients, including those with irregular corneas. At the same time, ReLex SMILE promises to be the next procedure on the horizon. It has a theoretical benefit of better preserving the biomechanical strength of the cornea and potentially reducing side effects such as dry eyes. However, it also has its own set of limitations, and we await more and more systematic scientific studies for this procedure. Until then, Lasik still remains the most widely sought after option for refractive surgeons.
These are exciting times for clinicians and scientists. In the end, it is through a thorough dissection of controversial clinical and surgical modalities, that we will get the path forward.
ESCRS Endophthalmitis Study Group. Prophylaxis of postop- erative endophthalmitis following cataract surgery: results of the ESCRS multicenter study and identification of risk factors. J Cataract Refract Surg 2007; 33:978–988