The Best Interest of the Patient
In April’s “Glaucoma Grand Rounds,” James L. Fanelli, O.D., describes the case of a 77-year-old patient with end-stage glaucoma in both eyes, right greater than left, and a visually significant cataract in the left eye. He writes that after considering her history and her exam, “I elected not to proceed with cataract surgery.” Does Dr. Fanelli perform cataract surgery? If not, why did he phrase that sentence as he did? Did he consult with a cataract surgeon regarding this patient?

From the perspective of an actual cataract surgeon, his conclusion may have been appropriate, but his rationale is suspect. His decision not to have her proceed with cataract surgery was based on the presence of posterior synechiae and that she is taking methotrexate for rheumatoid arthritis, which could indicate that she would develop “an exaggerated postoperative inflammatory reaction.” I have performed many cataract procedures on patients with posterior synechiae and/or taking immune suppressants for autoimmune disorders, with no experiences of uncontrolled or even problematic postoperative inflammation. Frequently, we perform cataract surgeries on patients with significant histories of uveitis as long as the inflammation has been controlled—no cell or flare—for several months.

I would share a reluctance to “rush” to operate on her cataract due to the severity of her visual field loss and the extent of her optic nerve damage. There would be a lengthy discussion with an emphasis on the risks, but if she considered her vision to be impaired in a way that was making her life less enjoyable or was affecting her normal activities in a way that cataract surgery could reasonably be expected to improve, I would not deny her that choice. One factor in her favor is that she has a functioning filtering bleb on that side that would effectively blunt any short term IOP spike that can be devastating in cases like hers.

I hope optometrists in my community are not making these determinations for their patients without consulting with appropriate, conservative (as opposed to aggressive) eye surgeons. Our patients deserve all the information available, from the doctors with the most experience, to help them make the best choices for themselves.

—Brian T. Rose, M.D.
Tempe, Ariz.

Dr. Fanelli responds:
I would like to thank Dr. Rose for taking the time to comment on the case concerning a patient with end-stage glaucoma in both eyes, a visually significant cataract O.S., and a condition that could potentially complicate her postoperative cataract course in her (essentially) only seeing eye.

Dr. Rose seems to take issue not with the management decision I made, which was not to have the patient proceed with cataract surgery, for he says, “his (Dr. Fanelli’s) conclusion may have been appropriate” and “I would share his reluctance to 'rush' to operate on her cataract.” It seems, though, that Dr. Rose’s concern, and reason for writing, is the fact that I came to this conclusion on my own. I base that observation on the questions he poses, which seem to indicate his anxiety for an optometrist rendering an opinion without consulting “doctors with the most experience,” who are, according to Dr. Rose, eye surgeons.

To answer Dr. Rose’s specific questions: Do I perform cataract surgery? No, I do not. I am an optometrist. Did I consult with a cataract surgeon regarding this patient? No, I did not. I do commend Dr. Rose for reading the column and coming to the same appropriate opinion I did after evaluating the patient.

While sometimes complex, opinions are educated management plans based upon patient specifics and the judgment of the individual provider. Two providers may look at the same patient and render different opinions. When indicated, I often seek the opinions of other consultants with whom I work closely. Fortunately, in many communities across the U.S., there are numerous, well-trained optometrists capable of making such decisions on their own. I am glad that Dr. Rose and I are both approaching this case from the perspective of what is in the best interest of the patient. We differ though, in whom we think can determine this.

Something’s Fishy Here
It was great to see the article by Dr. Larry Alexander discussing the details of fish oils in nutrition ( “The Slippery Facts About Fish Oil,” May 2010). This is an area of nutrition that seems to be generating a lot of interest as well as some controversy.

While I appreciate the information offered in the article, a few issues don’t seem to add up. First, Dr. Alexander talks about how fish oils as supplements are necessary because our diets and other factors keep us from getting the proper amounts of EPA and DHA. Yet, in the very next paragraph he quotes the American Heart Association recommendations that mostly promote fatty fish as the best source (with supplements only for the higher therapeutic dosages).

Additionally, omega-3 fats found in fish are the only “natural” triglyceride (TG) form, which is 18:12 (EPA/DHA ratio). All concentrated fish oil is “synthetic,” whether EE (ethyl ester) or TG. They are both molecularly distilled and normally concentrated at 30:20 or above. The concentrated form of TG fish oil has the glycerol backbone chemically re-attached, so is essentially “synthetic” as well.

The area of bioavailability is also an area that I found of interest. Studies suggest that within the first 24 hours after ingestion, TG fish oil is more rapidly absorbed. However, after 24 hours, cellular levels of EPA/DHA are identical between the two forms. Thus, if someone is taking fish oils on a daily basis, the rate of absorption in the first 24 hours becomes a moot point. The highly concentrated, FDA-approved prescription fish oil Lovaza (GlaxoSmithKline) is in the EE form.

Dr. Alexander has made many contributions to our profession and nutrition education and I always appreciate his opinions and his work with the Ocular Nutrition Society.

—Jeffrey Anshel, O.D.
President, Ocular Nutrition Society