Eye Care Blog

A plastic lens placed in the eye where the original crystalline lens used to be seems the ideal method of correcting the vision of a patient who has undergone cataract removal. Normally the crystalline lens has an optic power of nearly 20 dioptres, equal to a strong magnifying glass, and obviously an eye of normal size requires this power to be replaced. An implanted artificial lens is one way to achieve the necessary correction. It is wrong, however, to suppose that once the operation has been performed the patient will be able to see clearly immediately. This can only occur if the implant has been expertly placed in the eye, and if the right adjustments to the optic power, using spectacles, have been made. It is sometimes necessary to perform a second, less difficult operation after a few weeks have gone by.

The alternative is to fit contact lenses where this is possible, again a month or two after cataract surgery. For patients who have had a cataract operation on both eyes, or whose other eye is of no significant use, the remedy is spectacles. However, in cases of post-cataract prescription it is extremely important that exactly the right spectacles, made of plastic and correctly set, are provided, otherwise problems can occur.

There is a great deal of debate as to what is the most suitable method for dealing with cataract and the post-cataractus eye. There is no doubt that a well-placed intra-ocular implant gives the patient most satisfaction, but the risk of something going wrong in the long term is greater than for the eye without an implant; and every surgeon has to state what he considers the risk, or risks, to be to the individual patient before agreeing to operate.

The patient may inquire what are the risks of an implant going wrong over a period of, say, five years. And what will the problems be? The answers could be as follows:

In a bad surgeon’s hands (or in the hands of a good surgeon on a bad day), there is a one-in-ten chance of problems arising within a five-year period. This still leaves nine out of ten very happy patients, but one out of ten with poor vision and even a painful eye. A 90 per cent success rate sounds wonderful if you are practically blind and want the operation, but to be among the 10 per cent and know that alternative methods of surgery were available is unacceptable. One in a hundred failure rate, on the other hand, would be acceptable to almost everyone. It is worthwhile, therefore, considering what the alternatives are, and whether there are ways of improving implant surgery to attain the required success ratio.

Implant lenses are made of plastic, and therefore the first precaution is to use only those implants whose materials are registered with a reputable health authority. This will ensure that the lens is of a known standard, and has undergone stringent laboratory tests. Unfortunately ophthalmology, like any other profession, has its cowboy practitioners. Secondly, the optical qualities of the implant lens should be of known accuracy. The surgeon should himself take the responsibility of ensuring that the lens he is inserting is of the correct power. The implant itself must be sterile, and handled in such a way as to keep it sterile. Long-term complications are most frequently concerned with the degree of injury inflicted upon the internal surfaces of the eye during surgery. Some abrasion is inevitable, but an experienced surgeon will know how to keep this to a minimum. It is also thought that some materials are likely to cause retinal damage in the long term. Because implant surgery is a relatively recent innovation, there is inevitably an air of hypothesis about some materials, but even so where there is a known risk there is always an element of greater risk in the hands of an average surgeon inexperienced in implant work.

But, it must be asked, how does the surgeon gain the necessary experience unless he is able to ‘learn from his mistakes’? Although in a well-ordered surgical practice maximum attention is given to providing the young surgeon with learner facilities (i.e. sitting in on operations performed by senior surgeons), there is no entirely satisfactory solution to this problem. Also, the skill of the surgeon does not simply depend upon how much experience he has had. There are natural surgeons, just as there are natural pianists, or natural tennis players. And so there is no guarantee that a young surgeon will not perform an operation less well than his more experienced colleague. This is of little consolation to the patient who has fallen into the hands of an untalented doctor, but perhaps it should always be remembered that the consequences of no surgery at all would in the great majority of cases be the greater evil. Like bad news, bad surgery attracts the most comment and attention. Provided that the medical authorities are vigilant in the maintenance of the highest possible standards, in the interests of general improvements it seems that we should be prepared to accept that things do go wrong from time to time.

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