Re: How do you select an eye surgeon for cataract surgery?

IMHO, you would be on stronger legal grounds recommending cataract
surgery to someone who obviously "needed it," than by co-managing a
patient whom you "non-recommended" having LASIK and the patient didn't
like the outcome, or suffered ectasia. Whether you recommend a
treatment or not has nothing to do with negligence.

But, your points are well-taken for the most part.

DrG

Anon E. Muss wrote:
On 2 Jun 2006 05:27:30 -0700, "Dr. Leukoma" <drg@xxxxxxxxxxx> wrote:

Wow. Since when is cataract surgery entirely elective?

When not having it does not result in significant risk of morbidity
(hypermature cataract) or impair my ability to assess the status of
the fundus.

Other than that, it's elective. It's certainly not going to "hurt"
the patient who choses NOT to have cataract surgery in most cases.
What "bad" happens if they don't have the surgery? Nothing -- except
they just don't see better.

In a real sense, every surgery is elective. People can choose not to
have retinal detachment surgery, not have malignant hypertension
treated, not be treated for a corneal ucler, etc. In those cases I
strongly recommend against not having those treated. I give them the
reasons why they should and what will most likely happen if they do
not. If they choose not to, I would do my best to insist they at
least see another doctor for a second opinion and do I everything I
could medicolegally to protect my rear.

The end result of a cataract is loss of visual function. The only
"elective" aspect is how much vision loss is tolerable to the patient.

Exactly. It's up to the PATIENT to decide when the visual function
has been degraded to the point where the patient DESIRES the surgery.

I do not say, "Your vision is 20/50, you can't pass the DMV test, I
recommend you have cataract surgery."

I essentially say (this is paraphrased, I go into far more detail that
this, but I hope you get the idea) "Your vision is 20/50, you can't
pass the DMV test, if you want to be able to see better, then cataract
surgery is required. What do you want to do?"

There are also common standards, such as requirements for the
operation of a motor vehicle.

I, like you I am sure, have a few patients who have 20/80 cataracts
that don't drive and their vision is adqeuate for their demands. IOW,
they have no complaints. I don't recommend elective cataract surgery
for those patients.

LASIK, on the other hand, is elective in virtually all situations.

Yes. And for that very same reason, I never RECOMMEND refractive
surgery. Our office has comanaged a few hundred patients, and I
believe for the right patient, it is a great option. But I let the
patient tell me this is what they want versus this is what I think
they need.

The last thing I would want a patient of mine who had a poor result
from refractive surgery to have heard/be in their chart is that I
recommended they have refractive surgery.

Somehow, I believe that our patients expect us to be more than just
spouting fountains of statistics.

Certainly.

Regardless, for medicolegal reasons, I don't *recommend* (IOW, "You
should have") elective surgeries -- but that's just me. I say IF YOU
WANT X, then you need to do Y. Or I might say, for you, I believe
contact lenses would be the best option. It's a subtle, but important
distinction -- at least for me.

In fact, I don't recommend contact lenses either -- I examine their
eyes and offer options. I might say that contact lenses offer
advantages for you that spectacle and refractive surgery does not --
and if I were you, I would certainly go with contact lenses. It's all
about giving my patients options and informed consent.

I do make recommendations all the time though. I recommend people do
not sleep in their contact lenses (sometimes I do more than recommend,
other times I tell them). I recommend people with diabetes get at
least yearly comprehensive eye examinations. I recommend people with
significant glaucoma risk factors, such as elevated intraocular
tensions or suspicious or characteristic optic nerve appearance,
undergo a glaucoma workup. I tell my monocular or very young
patients, "Your lenses NEED to be in polycarb or trivex. However, I
recommend trivex." I strongly recommend nearly every patient who
wears contact lenses have a backup pair of glasses. I recommend
antireflective coatings for the vast majority of my patients. I
recommend hi-index lenses for many. For patients that choose soft
contact lenses, I almost always recommend a silicone hydrogel over a
HEMA lens.

Basically, I don't make recommendations that I feel, worse case
*realistic* scenario, I would be uncomfortable defending my actions
against in a court of law. Every doctor has their own comfort zone.

If I "recommended" a patient had non-elective cataract surgery, and
that person ended up having a horrible complication, say
endophthalmitis, and I got sued, I would not feel comfortable
defending a recommendation of cataract surgery. Lawyers, IMHO, are
too nasty, heavy-handed and zealous in their clients interests.

Read articles by Jerome Sherman -- I'm sure you know who he is. He's
at Suny and does a lot of malpractice and expert witness stuff. You
might be surprised at the stuff that people get sued for and lose in
when it comes to Optometry malpractice.

I'll give you one last example where I might differ:

I haven't taken a poll, but from informal discussions with them, most
of my colleagues feel that for a patient who presents with the chief
complaint of a symptomatic PVD, that an unremarkable standard
binocular indirect examination (BIO) is adequate from a medicolegal
standpoint.

It's not. I don't think it's even debateable.

There are NO reliable symptoms that can rule out a symptomatic PVD
from a retinal tear.

And to rule out a retinal break, one needs to perform careful and
meticulous BIO *with scleral depression 360 degrees* in both eyes. And
acceptable alternative is to use a Goldmann-type 3-mirror lens.

Standard BIO alone is failure to meet the standard of care. And if a
small retinal tear was missed because of failure to perform scleral
depression which then progressed to RD which causes permanent vision
dysfunction, I would be unable to defend such a doctor's actions.

If a doctor DID perform BIO with scleral depression and missed it,
then I would find no fault because that doctor met the standard of
care. That would however need to be documented in the chart.

An eye doctor needs to perform BIO with scleral depression (or careful
Goldmann 3-mirror examination of the periphery) for every patient that
presents with a symptomatic PVD, or refer that patient to a doctor
that can or that is malpractice if something goes bad as a result.

Do most Optometrists do this on every patient that presents with a
PVD? In my experience, no. Do most Ophthalmologists do this? No, in
my experience. They play an odds-game. Do most retinal surgeons do
this? In my experience, they do.

.