Correspondence They will encourage governments to homogenize surgical practices; remove our choices of techniques, instruments, and IOLs; and present an almost insurmountable legal and administrative obstacle to future innovation in Canada. Steve Arshinoff York Finch Eye Associates, Toronto, Ont. Correspondence to Steve Arshinoff, MD: iﬁ[email protected]
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Canadian clinical practice guidelines for cataract surgery—Author reply (Canadian Ophthalmological Society evidence-based clinical practice guidelines for cataract surgery in the adult eye.Vol. 43[Suppl. 1])
was intrigued that Dr. Arshinoff chose to begin his critique of the Canadian clinical practice guidelines for cataract surgery by quoting Marc Antony’s famous speech at Julius Caesar’s funeral: “I came to bury Caesar, not to praise him.”1 This speech is famous not only for its wonderful language but also for the clever rhetoric that Antony uses to convince his audience that Caesar was right and Brutus was wrong.2 Arshinoff asserts that the guidelines should not have been created, having warned that they “would be used by hospitals and jurisdictions to prevent innovation.”1 I believe that this is misleading; I believe that hospitals and jurisdictions are not concerned about innovation but risk, and the guidelines discussion on this point is very clear. Simultaneous bilateral cataract surgery (SBCS) was felt to be acceptable in some circumstances but was not considered to be appropriate for routine cases. The reason is straightforward: the risk of simultaneous catastrophic visual loss in both eyes secondary to cataract surgery is only present if both cataracts are operated on simultaneously. This position is completely consistent with the guidelines published by the American Academy of Ophthalmology3 and the Royal College of Ophthalmologists in the U.K.4 Arshinoff seems to suggest that his personal experience proves this is an unwarranted concern. I have attended the course that he chairs at the American Society of Cataract and Refractive Surgery—he and his fellow advocates of SBCS maintain that these complications will not occur as long as the surgeon is meticulous to all details related to the case. As I am writing this letter we are experiencing an epidemic of toxic anterior segment syndrome related to the injection of Avastin for wet macular degeneration in at least 8 centres in Canada. I am
REFERENCES 1. Canadian Ophthalmological Society Cataract Surgery Clinical Guideline Expert Committee. Canadian Ophthalmological Society evidence-based clinical practice guidelines for cataract surgery in the adult eye. Can J Ophthalmol 2008;43:S7–57. 2. Delpero W. Clinical practice guidelines: death for the art of medicine? Can J Ophthalmol 2008;43:517–9. 3. Bellan L. Canadian clinical practice guidelines for cataract surgery: it’s about time. Can J Ophthalmol 2008;43:519–21. 4. Masket S. Consultation section. Cataract surgical problem. J Cataract Refract Surg 1997;23:1437–41.
certain the retinal surgeons who performed those injections felt that they were performing their injections in the same, safe manner that they have been doing for years. Unfortunately there are aspects of every surgical procedure that are not under any surgeon’s control. Arshinoff is critical of any guidelines because they are “based on panel consensus [and] tend not to look forward, but backward—not representing ‘best practices,’ but rather ‘most commonly accepted practices.’”1 He suggests that they are impediments to progress “especially when a proposed change is complex and requires considerable learning.”1 How then are we to determine if these bold steps are actually progressive? The fallacy in his argument is that new is always better. Instead, I would suggest that only those new ideas that stand up to scientiﬁc scrutiny and to the test of time become best practice. This is exactly what the guidelines process attempts to identify. Arshinoff implies that clinical practice guidelines stiﬂe innovation. If this were true then all cataract research would have ended in the U.S. and the U.K. with the ﬁrst publications of guidelines decades ago. I contend that the frequent updating of these guidelines because of important innovations and the continuing expansion of ophthalmic medical literature show that innovation is ﬂourishing. It is interesting that Arshinoff agrees with the Canadian Ophthalmological Society (COS) board that there appears to be a need to guarantee a minimum standard of practice but argues that this can be better achieved through education rather than guidelines. Unfortunately Arshinoff’s faith in education is not shared by the leaders in the ﬁeld of continuing medical education (CME).5 Conventional methods of CME are not believed to be effective in producing fundamental change in physicians’ patterns of practice. Guidelines are clearly felt to be an important service provided by specialty societies to help their membership appreciate what is state-of-the-art care at a particular point in time. Rather than being an “act of arrogant self-aggrandizement,”1 they are a difﬁcult task undertaken by a committee with broad representation. The ﬁnal product is critiqued by CAN J OPHTHALMOL—VOL. 44, NO. 1, 2009
Correspondence many external reviewers before it is ultimately reviewed and endorsed by the society itself. I am proud of the guidelines that the COS committee produced and am happy to praise them rather than bury them. Lorne Bellan Chair, COS Cataract Surgery Clinical Practice Guideline Expert Committee Misericordia Health Centre, Winnipeg, Man. Correspondence to Lorne Bellan, MD: [email protected]
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2. Bloomﬁeld J. But Brutus is an honourable man: Mark Antony’s funeral speech in Julius Caesar. Suite101.com. Available at: http://shakespeare-tragedies.suite101.com/article.cfm/but_ brutus_is_an_honourable_man. Accessed December 3, 2008. 3. American Academy of Ophthalmology. Cataract in the adult eye. Available at: http://one.aao.org/asset.axd?id=821cecfb85c5-400d-a65f-7a9a727bc163. Accessed December 4, 2008. 4. The Royal College of Ophthalmologists. Cataract surgery guidelines. Available at: http://www.rcophth.ac.uk/docs/publications/ published-guidelines/FinalVersionGuidelinesApril2007Updated. pdf. Accessed December 4, 2008. 5. Fletcher SW. Continuing education in the health professions: improving healthcare through lifelong learning. Available at: http://www.josiahmacyfoundation.org/documents/Macy_ ContEd_1_7_08.pdf. Accessed December 4, 2008.
1. Arshinoff S. Canadian clinical practice guidelines for cataract surgery. Can J Ophthalmol 2009;44:98–9.
Diabetic retinopathy screening (Comprehensive teleophthalmology examination.Vol. 43)
e would like to thank Greve and Tennant1 for their comments in the editorial accompanying our article2 in the December 2008 issue of the Candian Journal of Ophthalmology. Although diabetic retinopathy is a treatable eye disease, it remains a leading cause of blindness in industrialized countries. Despite efforts to educate both patients and physicians about the importance of routine diabetic screening and despite the publication of Canadian screening guidelines, a large percentage of the diabetic population continues to receive inadequate retinopathy screening.3–6 This has led to the search for strategies to better detect vision-threatening retinopathy and reduce the incidence of complications and blindness from diabetic retinopathy.7 Diabetic retinopathy is an important public health concern requiring targeted examinations to obtain improved vision outcomes. Although new developments in technology make comprehensive teleophthalmology possible, the best strategy for diabetic retinopathy may or may not require a comprehensive eye examination. A screening strategy speciﬁcally designed for diabetic retinopathy in a public health context may not need to provide a complete eye examination, just as screening for colon cancer does not entail a comprehensive gastrointestinal workup. Screening must be separated from diagnosis, treatment, and followup where a more sophisticated setup and technology are probably necessary.
CAN J OPHTHALMOL—VOL. 44, NO. 1, 2009
Screening for diabetic retinopathy addresses a very specific public health need and results in better awareness, education, and access to reliable screening. In addition, such a screening strategy for diabetic retinopathy is supported by international scientiﬁc literature. The screening strategy and methods used in our study are in accordance with published literature and public screening programs in other parts of the world, such as the U.K.8 Greve and Tennant1 have expressed some concern about using pharmacies as an entry point for a screening program, and suggest the use of family doctors and endocrinology ofﬁces as a more sustainable option, a strategy that has until now failed to reach diabetics efﬁciently. Our intent was not to dictate a single program for teleophthalmology diabetic retinopathy screening, but to demonstrate the signiﬁcant health results that can be obtained when screening is provided for these patients with diabetes. The use of pharmacies as an entry point is only one possible solution to the problem of accessibility. Physicians are very effective at providing care to a captive patient population in a health care setting, but in order for a screening program to be beneﬁcial, we need to target the population outside traditional medical settings. Different populations and regions may require different solutions, and we need to be creative in our outreach methods to maximize the general population’s exposure to timely screening. We believe that efforts to improve screening rates need to be multifaceted and that better access to rigorous, reliable, and timely screening services for diabetic retinopathy offers the best chance of preventing disease and preserving the vision of our diabetic population. We are adamant that government health authorities need to become more involved