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“When I consider how my light is spent, Ere half my days, in this dark world and wide” wrote Milton in the sonnet “On His Blindness”1 when life expectancy was much shorter than it is as we approach the millennium. By the end of this century 6.5% of the population of the European Union will be aged 75 and over.2 Evans and Wormald3 have shown an increase in blind registrations attributed to age related maculopathy (ARM) in the order of 30–40% from 1950 to 1990. The Melton Mowbray study4 has shown prevalence rates for any ARM of between 82% and 86% with drusen found in 72.8% of the population aged 77–90. This is the same age group that develops cataract, and to complicate matters further the Beaver Dam study showed that nuclear sclerosis was associated with increased odds of early ARM.5
Pollack et al 6 found that progression of ARM occurred more often in eyes after cataract surgery compared with fellow eyes, with the risk factors identified those of male sex and soft drusen. They have postulated along with others that the presence of a cataract may protect the eye from phototoxic injury in the presence of ARM but van der Schaft and colleagues7 did not find anything to confirm this.
If we are going to offer cataract surgery what do we say to the patients to provide them with realistic expectations? I was greatly helped with the answer to this question by reading the paper by Shuttleworth et al in this issue of the BJO(p 611). I now tell patients with coexisting ARM that, following surgery, there is a two thirds chance that they will feel the operation has been worthwhile with a one third chance that they will feel the operation has not been worthwhile. Shuttleworth and colleagues admit that the presence of ARM is lower in their study with only 9% of patients undergoing cataract surgery during that period having pre-existing ARM. This paper would have helped even more if the authors had been able to identify predictors of surgical outcome. However, they propose a prospective study which will lead to the development of guidelines for the management of patients with cataract and ARM.
Should we expect patients with cataract and ARM to undergo an operation when there is a one third chance that they will not feel the surgery has been worthwhile. Shuttleworth and colleagues’ paper shows that 17% had mixed feelings and 17% thought it not worthwhile. We know from other work on patient satisfaction with visual function following cataract surgery that approximately 10% in all series of patients undergoing cataract surgery are not entirely happy with the outcome. If this study is looked at compared with these figures then it certainly does seem worthwhile to operate on patients with cataract and ARM. As a cataract surgeon I have frequently been confronted with patients who were told 10 years previously that they must never let anybody touch their cataract as they had ARM. One of my patients went from being registered blind to returning to drive following cataract surgery having been put off surgery for years! This is unusual but while the jury is out on cataract surgery in the presence of ARM do we as surgeons “also serve who only stand and wait”.1 I would suggest that we do not serve our patients well by standing and waiting but rather we should discuss honestly the available facts and figures; in this regard the work of Shuttleworth et al is most helpful and I look forward to their next study.