Dear Cyndy,

Thank you for your letter.

Here are my uncensored and unedited thoughts about your
scheduled cataract surgery:

1. I have no business intruding into your medical decision-making.
2. My thoughts may well reflect: a) my own (relative) surgical
incompetence, and b) subconscious compensation for the faulty
advice I have given my patients over the years.
   If my memory serves me correctly,
3. you were initially quite critical of your ophthalmologist,
comparing him to a used car salesman.  Subsequently you accepted him
because you considered him technically competent, because there was
no practical alternative.
4. When you first consulted him for blurred vision (acuity of the order
of OD 20/30, OS 20/50), he told you you had macular degeneration and
cataract surgery would be of no benefit.
5. You continued to pin your hopes on cataract surgery, and extracted
from him the statement that "in the spring" the eyes might be ready
for surgery. That prediction is profoundly perplexing to me, because
though I have cared for many patients in your situation, I have never
been capable of such a look into the future.
a) Occasionally in the course of six months, the cataract does indeed
become so much more dense, that cataract extraction becomes imperative
and is likely to bring about great improvement in vision.
b) Occasionally the cataract shows little change but the macular
degeneration progresses and accounts for deterioration of vision.
Under such circumstances cataract surgery will brighten the appearance
of colors, but will not improve visual acuity.
c) Frequently there is no objective change in the cataract at all,
and the surgery is performed as implementation of a prediction and a plan.
6. I acknowledge that scheduling cataract surgery to be done in short order
on both eyes, one after the other, is common practice. It has never made
sense to me for the following reasons:
a) if the operation on the first eye is successful, the patient's visual
function is for practical purposes fully restored, even if the fellow eye
is blind. Such is my situation. I had cataract extraction in my right eye
in 1996 with good visual result. Subsequently the left eye has become blind
from cataract to the level of light perception only. The circumstances
that I have been able to practice ophthalmology, drive to Virginia and back,
work on the Nantucket project, and write letters to you, persuades me that
it has been unnecessary to have the left cataract removed. 
b) A conscientious surgeon (oxymoron?) would learn by observing the
operated eye not for months, but for years. Did the surgery accelerate the
macular degeneration? Did it ultimately bring about retinal detachment?
Was it followed by glaucoma?
c) The representation that cataract surgery is uniformly safe and
uncomplicated is false. Surgeons can't afford to keep track of their
bad results; but the incidence of endophthalmitis (which leads to severe
impairment of vision when it does not cause blindness) is about 1:1000
with, and 1:10000 without intraocular lens implantation. To what degree
macular degeneration is exacerbated by cataract surgery is an unanswered
question, but it is common enough to see post-cataract patients whose
macular disease is worse after the surgery. If cataract surgery does
accelerate macular degeneration, then by postponing surgery on the
second eye as long as possible, you might spare yourself the agony of
severe visual disability before you die.
d) A patient of mine whom I had treated for glaucoma for thirty-five
years just died a few weeks before her hundredth birthday. At the time
of her death she was still able to read, albeit with difficulty.  When I
sent her for cataract surgery for her right eye 10 years ago, the glaucoma
was well controlled. Subsequent to uncomplicated cataract surgery, the
glaucoma in the right eye became more severe and difficult to manage.
Ultimately the glaucoma in the right eye became unmanageable and required
glaucoma surgery. In order to avoid sensory deprivation, I persuaded her
to have the cataract in the left eye removed prior to the glaucoma surgery
to the right eye. Subsequent to the cataract surgery in the left eye, the
glaucoma in that eye also became uncontrolled. Had both eyes been operated
at the same time, the patient might well have been blind for the last months
or years of her life. The surgeon who did the operations has no idea of
what went on.  He never asked me. He doesn't care. This patient is not the
only one.  I have two other patient stories to tell, but my letter is already
far too long and detailed. But you get the picture, and perhaps you
understand why, when you wrote me your were about to have both eyes
operated on in short order, I couldn't sleep.

I understand well, my middle name should have been Cassandra. If I were
responsible for an airline, there would be parachutes for all the
passengers, just as on the Nantucket ferry there are life-preservers
for everyone and life-rafts to accommodate us all. But my airline would
be insolvent; in fact, it would never get off the ground, because no
passenger in his right mind would board an airplane that might crash.
For decades, my colleagues have been intent on trivializing cataract
surgery.  The circumstance that the patient is no longer required to
undress prior to surgery is adduced as evidence that the operation
is a minor matter. "A piece of cake," as patients say, "nothing to it."
They are persuaded to "have their eyes done", with the same nonchalance
with which they have their hair done. And who am I to object?

=============================

I'm very sympathic with Ned. I also can do without vistors;
and I also don't want my wife traveling abroad in search of
entertainment. You stay home and be good, give my best to Ned,
and ignore what Cassandra wrote.
Jochen