EWAP MARCH 2024 3 EDITORIAL EyeWorld Asia-Pacific • March 2024 • Vol. 20 No. 1 “ Graham Barrett Chief Medical Editor EyeWorld Asia-Pacific • China • Korea • India T he Greatest Teacher” evokes thoughts of mentors we have had in our pre- and postgraduate training who have had such a dramatic influence on highlights and careers. Nevertheless, I would suggest the “Greatest Teacher” also applies to our patients and clinical experience over many years. This is particularly the case when discussing considerations for proceeding with cataract surgery. Several experts provide their thoughts and bring to my mind how I counsel my patients, in that the decision to proceed with cataract surgery typically does not rely on the appearance of the cataract or what they read on the chart but rather the difficulty they are experiencing with the clarity of their vision. Once they have reached the stage where the quality of their vision is unsatisfactory for near or distance then proceeding with surgery is advisable as the symptoms will only progress. Naturally, this is accompanied by a discussion on the risks of surgery as well as letting them know that in addition cataract surgery does provide an opportunity to reduce dependence on spectacles. There are of course exceptions. Sometimes, the density or maturity of the cataract is such that deferring surgery may lead to a greater risk of complications. A similar situation arises when there has been recent angle closure, the risk is considered likely, or a previous attack has occurred where removal of the lens is advisable. On the other end of the spectrum, be wary of patients with visual complaints where the density of the cataract does not appear compatible with the symptoms. A recent patient was referred for surgery in his 70s with corrected acuity of 6/6. There was early nuclear sclerosis but his description of visual difficulty was vague and did not match the density of cataract. I performed visual fields and found a bitemporal loss, which was confirmed on MRI to be a pituitary tumor. It is always wise to caution that the prediction of outcome is not 100% accurate despite the best methods of measurement and they will still require reading glasses unless a presbyopic strategy such as extended depth of focus or modest monovision is considered. The old adage of “under-promising and overdelivering” is certainly applicable. Many years after graduating, the decisions we make as ophthalmologists tend to be based on clinical training and the textbooks we have read. With experience however we increasingly consider the patient we have cared for over the years and the lessons we have learned from them—the Greatest Teacher. It is time for all of us to remember the fundamentals of being a physician — of partnering with the patient in managing their eye diseases. While we grow more and more confident of our technical and visual outcomes in uneventful cataract surgery, it is crucial to keep in mind that we time surgery not only based on our clinical judgement but also according to the patient’s desire. Often, what appears to us as the ideal cataract for surgery may not be causing a proportionate degree of visual disturbance for the patient. This is particularly true of nuclear sclerosis, where patients are often well adjusted and comfortable in their daily visual needs. As a surgeon, there is always the temptation to perform surgery; however, as a good physician, it is imperative that we respect the patients’ wishes. Despite the pressures of modern practice, we must not forget that the patient will appreciate your partnership in their eye care. Once the decision to undergo surgery is made by the patient, even if something goes wrong, they are more likely to tolerate it. On the other hand, if they were pushed into early surgery by your team, they will more likely find reasons to express their dissatisfaction in the postoperative period. Therefore, experience has taught many of us over the years that unless indicated urgently, cataract or refractive surgery for that matter is best performed when the patient is ready for it. There will be times when the patient may not understand the gravity of the situation, when you will need to sit them down and discuss the need for surgery and the potential risks associated with not performing timely surgery. Yet, as a rule, giving the patient the choice of when to operate will mean happier, more satisfied patients. What’s more, these very patients will be your ambassadors in society. One must therefore spend time before surgery understanding the patient’s visual needs, their expected outcomes from cataract surgery, and their anxieties. One of the features in this issue also talks about various approaches of dealing with anxious patients during surgery. What I have learned from experience is to maintain your own cool in the situation. Do not allow the patient’s anxiety to get to you. Be calm and focus on the surgical steps as best as possible. This issue distils the experience of several surgeons over the years and provides valuable pearls. In the long run, it is your clinical sense as much as your surgical skills that will yield rich dividends in practice. Abhay Vasavada The Greatest Teacher Deputy Regional Editor EyeWorld Asia-Pacific
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