EyeWorld Asia-Pacific September 2013 Issue

27 EWAP CAtArACt/IOL September 2013 Hungwon TCHAH, MD Professor, University of Ulsan, Asan Medical Center 388-1 Pungnab-dong Songpa-gu, Seoul, Korea Tel. no. +82-2-30103680 Fax no. +822-2-4706440 hwtchah@amc.seoul.kr M ichael J. Sandel, a professor of the Department of Government, Harvard University, wrote a book, Justice 1 , a few years ago. In it, he asked, “What is justice? What is the right thing to do?” He explained theories of justice based on utilitarianism (maximize utility, happiness), libertarianism (maximize personal freedom) and communitarianism (cultivate civic virtue). He somewhat criticized utilitarianism because a just society, he thought, could not be achieved by maximizing utility. He also stated that today the utilitarian logic, the principle of maximum good for the maximum number of people, is commonly used, under the name of cost–benefit analysis, by companies and by government, and what it involves is placing a value— usually a dollar value—to stand for utility on the costs and the benefits of various proposals. He then asked, “What is the price of the life?” We know it is priceless but in reality we put a price tag on it. What is the price of my right eyeball pain? I am very much sure insurance companies can calculate that price, too. Cost–benefit analysis is very important to preserve the limited resources and maximize the effect (this is actually utilitarianism’s purpose). But that is not all. We have to consider human virtue besides effectiveness. Use of newly developed expensive medication, which might not be cost–effective in terms of public health control, may be vital for saving an individual’s life which may be tagged a lower price. Sometimes I am surprised to find myself becoming a slave of effectiveness and to forget human virtue. Unfortunately, many medical insurance systems and government public health policies have been using utilitarianism’s cost–benefit analysis too much. Fortunately, not all of them do. I totally understand Dr. Noreika’s dissonance in femtosecond laser cataract. And I agree that there is not enough data showing that femtosecond laser cataract surgery is far superior to conventional phacoemusification cataract surgery. Furthermore, femtosecond laser cataract surgery requires more financial resources, which may be a new burden to patients, as Dr. Noreika mentioned. New technologies, however, in medicine or in any other field, do not come with enough data to show that they are absolutely, perfectly safer and more effective technologies than previous technologies, especially in their infant stages. I happen to be old enough to remember the ICCE and ECCE era. They were good techniques and patients were satisfied with the results. Then, a new cataract surgery technique—ultrasound phacoemulsification—appeared. How were the initial results? They were horrible. The phaco machine was quite bulky. Every single patient had corneal edema and the procedure was time consuming. There were more complications such as tears in the posterior capsule and nucleus drop into the vitreous cavity. But the technique evolved and evolved. Now no one can argue that ultrasound phacoemulsification cataract surgery is considered the standard cataract surgical procedure in most developed countries. Who knows? Femtosecond laser cataract surgery could be a standard cataract surgical procedure in 2020 to achieve 20/20 vision in every single cataract patient. As I mentioned, I totally understand Dr. Noreika and I agree with him. There are many questions to be answered before considering applying a new technology like femtosecond laser cataract surgery to any one particular patient. Some of the questions are difficult to answer at the moment. I will keep my hands cold to evaluate the femto technique thoroughly to increase the safety and benefit to my patient, but also will have a warm heart for this procedure unless it is definitively proved fundamentally hazardous to patients because it is a new technology and in the very early stage of its development. And because if we do not try anything new, there will be no advances. Reference 1. Sandel, Michael. Justice: What’s the right thing to do? New York: Farrar, Straus and Giroux, 2010. Print. Editors’ note: Prof. Tchah has no financial interests related to his comments. Sri GANESH, MD Chairman, Nethradhama Super Specialty Eye Hospital 256/14, Kanakapura Main Road, 7th Block Jayanagar, Bangalore-560082, India Tel. no. +91-80-26088000 Fax no. +91-80-26633770 chairman@nethradhama.org T he confusion (“dissonance”) regarding femtosecond cataract surgery among ophthalmic surgeons is very evident from this article. Like the famous quote in Shakespeare’s Hamlet—“To be, or not to be…”—the indecision in adopting femtosecond technology for cataract surgery is apparent in every conference, deliberation and scientific meeting. On one hand, there is an anxiety to quickly adopt new technology so as to harvest the maximum marketing potential and footfalls into one’s practice. On the other hand, there is apprehension on financial gains and return on investment coupled with a lot of peer pressure and industry-driven coercion that makes this decision more difficult. Any new technology that comes in should improve efficiency, safety, speed and clinical outcomes. With the femtosecond technology for cataract, this is not very apparent and benefit to the patient and clinical outcomes is at best dubious. The femtosecond laser is an excellent cutting tool for corneal and refractive surgery which has been accepted and adopted into these practices without much debate as the advantages are very apparent. There is a dissonance on various aspects of the femtosecond technology for cataract surgery, including surgical time and efficiency, cost–benefit ratio, comfort to patients, mediclaim and insurance issues and finally clinical benefits. Is it just a marketing tool or does it really benefit our patients? Time will tell. The femtosecond laser takes the skill out of some of the difficult steps of phaco surgery like capsulorhexis and nuclear fragmentation and is a very precise tool but does this translate into clinically significant benefits is something that will always be debated. As physicians, we will always have to look at patient’s safety and clinical benefits and also consider value for money, keeping in mind that most of these patients are retired pensioners with limited resources to pay for treatment. The final word on femto cataract surgery is still awaited as the technology is still in its infancy. Editors’ note: Dr. Sri Ganesh is a consultant for Carl Zeiss (Jena, Germany), Hoya (Tokyo, Japan), Bausch+Lomb (Rochester, NY, USA), Abbott Medical Optics (Santa Ana, Calif., USA), and Schwind (Kleinostheim, Germany), but has no financial interests related to his comments. Views from Asia-Pacific