Introduction

Published on 08/03/2015 by admin

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Last modified 08/03/2015

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CHAPTER 1 Introduction

We hope this text will continue to be a practical guide for the ophthalmic surgeon. Our goal is to present a comprehensive review of eye surgery in a single volume. We have attempted to be thorough without being exhaustive, as a truly complete commentary would fill many volumes. The vast increase in knowledge within each subspecialty area and the complexity of ophthalmic surgery have led to the introduction of many more specialized texts.

The techniques of ophthalmic surgery have proliferated so rapidly and extensively that a single surgeon cannot possibly be fully competent in all aspects. Those who dispute this fact are either unaware of the field or unaware of their own limitations. Indeed, one surgeon may not even be fully competent in all procedures within a single subspecialty area.

Fortunately for our patients and for our ease of mind, the majority of surgical eye diseases can be properly managed with relatively limited procedures. Thus, the ophthalmic surgeon need not be competent in every aspect of surgery in order to give excellent care. For example, a surgeon fully proficient in performing and managing a peripheral iridectomy, trabeculectomy, cataract extraction with lens insertion, and a tube-shunt procedure provides most glaucoma patients with fine care. There is a valid concept of a ‘core curriculum’ in the field of ophthalmic surgery; there is also a body of knowledge of greatest clinical value. We have tried to include here only material of essential clinical worth.

Inclusion of a procedure in this text does not indicate that all surgeons ought to be performing this operation. Obviously, some surgeons are more competent than others in performing certain techniques: some are better craftsmen; some better technicians; some have better judgment. A few surgeons are superb at all aspects of care.

Many factors play a role in the decision about where and by whom a particular surgical procedure will be best performed. An important consideration is that the patient has confidence in his or her surgeon, and that the confidence is deserved. For this to be the case the surgeon must be knowledgeable, procedurally skilled and have good judgment. Wherever possible, surgery should be performed at a facility close to the patient’s home. The surgical experience can itself be upsetting, and the support that comes from familiar surroundings is an important factor, especially for the very young and very old. For example, when surgery is performed at a distance from patients’ homes (such as in another city) and postsurgical complications occur, patients find themselves in the difficult position of trying to decide whether it is worth continuing the trips to the operating surgeon or whether it is wiser to return to the local physician. That surgery will be more expensive and inconvenient when performed at a distance also militates against referral for surgery.

On the other hand, certain factors favor referral even in cases where the patient has confidence in his or her local surgeon. If the local surgeon believes another surgeon is more competent in the required procedure the consideration of referral should arise. It is our impression that most patients are aware that complete success is not an invariable product of surgical treatment, and are thus prepared to accept results less desirable than hoped for. However, the entire foundation for this acceptance by the patient is based on an unwavering faith that the care he or she received was of at least standard quality. Moreover, there are numerous patients who will not be able to cope with a poor result unless they genuinely believe they received what is perceived to be ‘the best care’. Surgeons who care for patients but demonstrate a lack of confidence are courting catastrophe for themselves and their patients. In such circumstances, the local surgeon is not obligated to perform surgery when referral services are reasonably available.

In situations where the facilities or personnel for competent surgery are not available, it may be wise to avoid surgery entirely. A patient with useful vision but uncontrolled glaucoma will not be helped by a poorly performed procedure. Similarly, a person with 20/200 vision due to keratoconus or vitreous hemorrhage will not be benefited by a poorly performed corneal graft or vitrectomy.

In some regions of the world, whatever care is present is the best care because it is the only care. There are many other situations in which referral is considered unwise, for one reason or another. We hope that this text will assist surgeons operating in such circumstances. We also hope that it will provide helpful information to ophthalmologists when making decisions on what type of ophthalmic surgery to provide.

The craftsman, the technician, and the complete surgeon

From time immemorial people with pain, illness or injury have sought the help of ‘others’. The ‘others’ often develop skills and knowledge which distinguish them from those seeking their help. Over time, these ‘others’ were recognized as professionals: shamans, medicine men, iatromants, and other healers1,2. The healing methods included invocation of gods or spirits, exorcism of demons, applications of heat or cold, ingestion of herbs and drugs, and application of a variety of mechanical approaches: bodily manipulations, including couching of cataracts, and removal of unwanted materials such as thorns, pus, worms or tumors. In Europe the mechanical methods, which often involved cutting, became the purview of the barbers (then barber surgeons), or their offspring, surgeons35. The field of surgery, as we now know it, did not stem from in academic departments, or even from the field of medical practice, but rather from artisans dealing with physical problems. All too often limitations in technology predetermined that the result would be of limited help. The great surgeon of the past was fundamentally a great craftsman.

The development of technology is one of the most characteristic features of history over the last 200 years. In this period, industry developed and the scientific method became accepted as a fundamental aspect of medical and surgical care. During the last half of the nineteenth century, the image of the physician and the surgeon started changing from that of compassionate, but often ineffective prognosticators, to effective medical scientists. Prior to that time, physicians and surgeons were revered and rewarded primarily because of their ability to support patients during difficult times; this required mastery of the craft of medicine. Of course, many individuals also benefited from the mechanical skills of surgeons, as new approaches and technologies resulted in outcomes not previously possible. Nevertheless, great procedural skill continued to be the hallmark of the great surgeon.

Craftsmanship requires knowledge of the tools and materials used in performing one’s craft. In the craft of surgery, this includes surgical instruments, anesthesia, the knowledge needed to treat injury and understanding of the techniques and indications of the types of operative procedures. The surgeon must also understand the patient’s nature, needs, wishes, and his or her unique qualities at each interaction.

The craftsman is personally involved with his or her work, and therefore always carries a subjective component. The craftsman recognizes that each created work is unique. The technologist, on the other hand, attempts to remove oneself as much as possible from one’s work. Technology implies objectivity, standardization, and uniformity of results. The results of the technologist are relatively easy to measure, and hence performance is relatively easy to evaluate. On the other hand, the quality of the craftsman’s product is quite difficult to measure. Is, for example, Cellini’s Rococco salt cellar a ‘better job’ than the Cro-Magnon man’s flint arrowhead or Calder’s starkly simple mobiles? Furthermore, the process of creating is equally as important to the craftsman as the product itself. The surgeon as a craftsman learned by apprenticeship and was taught by example. His or her major activity was demonstrating care, and the product was not ‘cure’ but ‘care’.

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