“Wise pearls of refractive and cataract surgery revealed in charming style” review of 101 Pearls In Refractive, Cataract and Corneal Surgery. Eurotimes, Jan 2007

PDF of the original is here. I was always billed as “MD” by Eurotimes, despite repeated requests to change it on my part. This review is again fairly typical. My musings on evidence based practice and the possible return of clinical wisdom seem germane to the considerations I wrote about here . Credit to the subeditor for the haiku-like title (too many syllables though)

“Wise pearls of refractive and cataract surgery revealed in charming style”

There is something of a tradition in medical publishing of books claiming to provide “pearls” or “clinical gems” or “clinical secrets”.

These are never primary textbooks that could be used for study, but supplement basic knowledge, and mirror a learning technique of definite effectiveness.

We like to think the practice of medicine is a rational exercise, the application of knowledge gleaned from evidence-based sources and from a rigorous training in the basic sciences that underpin medicine.

The fact is, however, that our practice is very often based on the cases that stick in the mind, those that illustrate some point or other much more effectively than, let us be honest, any amount of high-minded praise of evidence-based practice.

After all, a little introspection will reveal that we remember the unusual, the striking, the individual, far more than the great mass of material we are instructed to recall. Of course, properly applied, evidence  basedpractice flows from the individual case to the peer-reviewed paper, and not the other way round.

Melki and Azar have assembled an international cast of contributors to produce this concise, clear, practical volume, which is aimed at practitioners and assumes a certain degree of familiarity with surgical technique, indication and practice. So this is a typical “pearls” book – not one for the student or the beginner but one for the active practitioner, guiding and advising the actual process of clinical medicine. In this case, the surgeon of the anterior chamber.

There is something charming and collegial about this approach, an approach that conjures up old-fashioned images of medical training and education as a body of knowledge handed down, apprenticeship style, from older practitioners to younger ones.The “pearls” book concept presumably began life as a compilation of the sayings of certain eminent clinicians.

Again, the current of medical education and training now – as well as reforms and/or tinkerings (delete according to taste) with medical training  – is towards self-directed,“problem-based” learning. Fashions change in medical training as much as any other field, and there is something to be said for the older approach. No doubt it will return to some degree.The notion of “expertise” of senior clinicians – or even not so senior ones – counting for much is old-fashioned in medicine.Yet have we lost something in the rush to elevate the meta-analysis of a series of double-blind randomised controlled trials as the measure of all things?

Claes H Dohlman, professor of ophthalmology at Harvard Medical School, contributes a foreword to this second edition as he did to the first edition. Dohlman writes of the apparent presumption of the editors in taking on three enormous areas in a single, relatively compact text.“However, instead of trying to grind through the topics in the traditional way, resulting in superficiality, the authors have cleverly singled out a series of discrete key issues along the cutting edge of this surgery.” Thus the “pearls” of the title.

So what are the pearls? Given that there are 101, the reader will forgive the absence of a list of each and every one.There are 25 subsections, aggregations of pearls so to speak, which begin with surgical planning with wavefront tomography and end with posterior keratoplasty. Each “pearl” is essentially a little section of text, with the accent on practical advice and issues, and at the end an “Always Remember” box succinctly summarises the crucial point. In between, every technical area is covered – as explained above and reiterated by Dohlman in his Foreword, this is not and does not claim to be a comprehensive textbook or, indeed, a manual of every single step of surgery, but a supplement to these sources. The pearls very often relate to the use of specific technologies in surgery, and practitioners may need familiarity with and indeed availability of these technologies to fully benefit from the book.

There is no doubt, however, that what is described is cutting edge, if the pun can be excused, and consistently reflects a high standard of practice which all practitioners should aim to emulate.The pearls also cover anaesthetic issues as well as those relating to particular points of surgical technique and preoperative work-up.

Thus, the relatively slim size and portability of the book. It is attractively presented, with good clear fonts on highquality paper, and a range of full-colour photographs and diagrams.The book I reviewed was a soft-cover edition with an attractively colourful cover. It is a snappy cover that reflects the snappy concept contained therein.

Overall, I was impressed with this book, which will complement comprehensive textbooks for the trainee ophthalmologist of the anterior section, with access to the technical innovations mentioned.

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