|
|
| Author |
Message |
JJ Lee
medicine forum beginner
Joined: 24 Mar 2006
Posts: 7
|
 Posted: Thu Jun 01, 2006 11:14 pm Post subject:
How do you select an eye surgeon for cataract surgery?
|
|
|
I'm a 40 year old male and need to have a cataract surgery in my right eye.
My aunt, a pediatrician, recommended an eye surgeon in my area. He has a
good reputation and 24 years of experience. I have high myopia, so he sent
me to a retina specialist to make sure my retina is fine. The specialist,
after examining my eye and doing OCT and FA, _convincingly_said to me, "You
don't have to see like this. Have a surgery and you'll see much better." In
contrast, my eye surgeon's take on my surgery is something like, "You MIGHT
see better." I think he's very cautious.
I know that at the end of the day it's the surgeon's skills that matter. I
guess my question is, "Would you be more comfortable with a cautious surgeon
or an assuring one?" |
|
| Back to top |
|
 |
Steven
medicine forum beginner
Joined: 26 Apr 2006
Posts: 5
|
| Posted: Thu Jun 01, 2006 11:47 pm Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
JJ Lee wrote:
| Quote: | I'm a 40 year old male and need to have a cataract surgery in my right eye.
My aunt, a pediatrician, recommended an eye surgeon in my area. He has a
good reputation and 24 years of experience. I have high myopia, so he sent
me to a retina specialist to make sure my retina is fine. The specialist,
after examining my eye and doing OCT and FA, _convincingly_said to me, "You
don't have to see like this. Have a surgery and you'll see much better." In
contrast, my eye surgeon's take on my surgery is something like, "You MIGHT
see better." I think he's very cautious.
I know that at the end of the day it's the surgeon's skills that matter. I
guess my question is, "Would you be more comfortable with a cautious surgeon
or an assuring one?"
|
I had cataract surgery a few years ago, and unfortunatley had *many*
complications. The end result is that I have very thick glasses and
still cannot see anywhere near 20/20, even in the one eye that still
works. Unfortunately this means that when it comes time to renew my
license it will be difficult.
Please be sure to get a cautious doc, but one who has done a lot of
these procedures. |
|
| Back to top |
|
|
William Stacy
medicine forum Guru
Joined: 01 May 2005
Posts: 1177
|
| Posted: Fri Jun 02, 2006 12:18 am Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
JJ Lee wrote:
| Quote: |
I know that at the end of the day it's the surgeon's skills that matter. I
guess my question is, "Would you be more comfortable with a cautious surgeon
or an assuring one?"
|
Neither. I would want (and sought out, in my case) the best I could
find. You want someone who does lots of them (at least 10 per week),
who uses all the latest techniques (stitchless, eyedrop alone
anesthesia, etc), AND who won't try to talk you into a multifocal or
"focusing" IOL.
w.stacy, o.d. |
|
| Back to top |
|
|
acemanvx@yahoo.com
medicine forum Guru
Joined: 15 Nov 2005
Posts: 732
|
| Posted: Fri Jun 02, 2006 12:52 am Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
JJ Lee wrote:
| Quote: | I'm a 40 year old male and need to have a cataract surgery in my right eye.
My aunt, a pediatrician, recommended an eye surgeon in my area. He has a
good reputation and 24 years of experience. I have high myopia, so he sent
me to a retina specialist to make sure my retina is fine. The specialist,
after examining my eye and doing OCT and FA, _convincingly_said to me, "You
don't have to see like this. Have a surgery and you'll see much better." In
contrast, my eye surgeon's take on my surgery is something like, "You MIGHT
see better." I think he's very cautious.
I know that at the end of the day it's the surgeon's skills that matter. I
guess my question is, "Would you be more comfortable with a cautious surgeon
or an assuring one?"
|
That sucks to have cateract(s) at only 40! The biggest problem is you
wont be able to tolerate glasses anymore due to anisometropia. Good
thing you never had lasik because it would have been "wasted" cause
cateract surgury also takes care of your myopia at the same time! How
bad is your vision in the affected eye? |
|
| Back to top |
|
|
JJ Lee
medicine forum beginner
Joined: 24 Mar 2006
Posts: 7
|
| Posted: Fri Jun 02, 2006 1:15 am Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
"William Stacy" <wstacy@obase.net> wrote in message
news:etLfg.37111$4L1.2926@newssvr11.news.prodigy.com...
| Quote: | JJ Lee wrote:
I know that at the end of the day it's the surgeon's skills that matter.
I guess my question is, "Would you be more comfortable with a cautious
surgeon or an assuring one?"
Neither. I would want (and sought out, in my case) the best I could find.
You want someone who does lots of them (at least 10 per week), who uses
all the latest techniques (stitchless, eyedrop alone anesthesia, etc), AND
who won't try to talk you into a multifocal or "focusing" IOL.
There's one doctor in my area (New York) who was voted as one of the best |
eye surgeons. If I should go for him, should I go through the tests (OCT and
FA) again? |
|
| Back to top |
|
|
Anon E. Muss
medicine forum Guru Wannabe
Joined: 22 May 2006
Posts: 136
|
| Posted: Fri Jun 02, 2006 5:57 am Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
On Thu, 1 Jun 2006 19:14:22 -0400, "JJ Lee" <jjlee@hotmoul.com> wrote:
| Quote: | I'm a 40 year old male and need to have a cataract surgery in my right eye.
My aunt, a pediatrician, recommended an eye surgeon in my area. He has a
good reputation and 24 years of experience. I have high myopia, so he sent
me to a retina specialist to make sure my retina is fine.
|
That was wise.
| Quote: | The specialist, after examining my eye and doing OCT and FA,
_convincingly_said to me, "You don't have to see like this. Have a
surgery and you'll see much better." In contrast, my eye surgeon's
take on my surgery is something like, "You MIGHT see better." I think
he's very cautious.
|
I NEVER recommend elective surgeries, like most cataract surgeries,
LASIK, etc.
I inform patients of the risks/benefits, tell them the pros/cons and
answer all their questions to the best of my ability. I tell them
THIS is your problem and THESE are the options (including doing
NOTHING). Then the patient makes their decision after being
completely and fully informed.
I never say, "You need to/should have (elective) cataract surgery", or
"You should have refractive surgery"*
That is IMHO asking for problem. If something bad happens, I do not
want the patient to be able to say, "YOU TOLD ME TO HAVE THIS
SURGERY!"
However, if asked, I will answer the question, "Well, what would you
do if you were me? Or what would you do if you were in the same
situation as I was?"
| Quote: | I know that at the end of the day it's the surgeon's skills that
matter. I guess my question is, "Would you be more comfortable with a
cautious surgeon or an assuring one?"
|
I'm not comfortable with ANY surgeon who RECOMMENDS a completely
elective surgery.
* (If a patient has a hypermature cataract, a cataract so dense that I
cannot adequately visualize the fundus details, then I will suggest
it. But that is like, maybe, <5% of the time.) |
|
| Back to top |
|
|
acemanvx@yahoo.com
medicine forum Guru
Joined: 15 Nov 2005
Posts: 732
|
| Posted: Fri Jun 02, 2006 6:20 am Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
That sucks to have cateract(s) at only 40! The biggest problem is you
wont be able to tolerate glasses anymore due to anisometropia. Good
thing you never had lasik because it would have been "wasted" cause
cateract surgury also takes care of your myopia at the same time! How
bad is your vision in the affected eye?
I noticed you didnt see what I said but please look up anisometropia. I
have seen people totally taken by supprise when they find they can no
longer tolerate glasses! |
|
| Back to top |
|
|
Dr. Leukoma
medicine forum Guru
Joined: 30 Apr 2005
Posts: 1283
|
| Posted: Fri Jun 02, 2006 12:27 pm Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
Wow. Since when is cataract surgery entirely elective? 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. There are also
common standards, such as requirements for the operation of a motor
vehicle. LASIK, on the other hand, is elective in virtually all
situations.
Somehow, I believe that our patients expect us to be more than just
spouting fountains of statistics.
DrG
Anon E. Muss wrote:
| Quote: | On Thu, 1 Jun 2006 19:14:22 -0400, "JJ Lee" <jjlee@hotmoul.com> wrote:
I'm a 40 year old male and need to have a cataract surgery in my right eye.
My aunt, a pediatrician, recommended an eye surgeon in my area. He has a
good reputation and 24 years of experience. I have high myopia, so he sent
me to a retina specialist to make sure my retina is fine.
That was wise.
The specialist, after examining my eye and doing OCT and FA,
_convincingly_said to me, "You don't have to see like this. Have a
surgery and you'll see much better." In contrast, my eye surgeon's
take on my surgery is something like, "You MIGHT see better." I think
he's very cautious.
I NEVER recommend elective surgeries, like most cataract surgeries,
LASIK, etc.
I inform patients of the risks/benefits, tell them the pros/cons and
answer all their questions to the best of my ability. I tell them
THIS is your problem and THESE are the options (including doing
NOTHING). Then the patient makes their decision after being
completely and fully informed.
I never say, "You need to/should have (elective) cataract surgery", or
"You should have refractive surgery"*
That is IMHO asking for problem. If something bad happens, I do not
want the patient to be able to say, "YOU TOLD ME TO HAVE THIS
SURGERY!"
However, if asked, I will answer the question, "Well, what would you
do if you were me? Or what would you do if you were in the same
situation as I was?"
I know that at the end of the day it's the surgeon's skills that
matter. I guess my question is, "Would you be more comfortable with a
cautious surgeon or an assuring one?"
I'm not comfortable with ANY surgeon who RECOMMENDS a completely
elective surgery.
* (If a patient has a hypermature cataract, a cataract so dense that I
cannot adequately visualize the fundus details, then I will suggest
it. But that is like, maybe, <5% of the time.) |
|
|
| Back to top |
|
|
William Stacy
medicine forum Guru
Joined: 01 May 2005
Posts: 1177
|
| Posted: Fri Jun 02, 2006 2:31 pm Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
JJ Lee wrote:
| Quote: |
There's one doctor in my area (New York) who was voted as one of the best
eye surgeons. If I should go for him, should I go through the tests (OCT and
FA) again?
|
Voted by whom? If you go to him, let him decide what to do. He will
likely be interested in what's already been done.
w.stacy, o.d. |
|
| Back to top |
|
|
Anon E. Muss
medicine forum Guru Wannabe
Joined: 22 May 2006
Posts: 136
|
| Posted: Fri Jun 02, 2006 3:56 pm Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
On 2 Jun 2006 05:27:30 -0700, "Dr. Leukoma" <drg@leukoma.com> wrote:
| Quote: | 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.
| Quote: | 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?"
| Quote: | 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.
| Quote: | 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.
| Quote: | 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. |
|
| Back to top |
|
|
Dr. Leukoma
medicine forum Guru
Joined: 30 Apr 2005
Posts: 1283
|
| Posted: Fri Jun 02, 2006 4:47 pm Post subject:
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:
| Quote: | On 2 Jun 2006 05:27:30 -0700, "Dr. Leukoma" <drg@leukoma.com> 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. |
|
|
| Back to top |
|
|
acemanvx@yahoo.com
medicine forum Guru
Joined: 15 Nov 2005
Posts: 732
|
| Posted: Fri Jun 02, 2006 8:16 pm Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
Dr. Leukoma wrote:
| Quote: | 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@leukoma.com> 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.
|
Cateract surgury is both elective and a neccessary. Someone who doesnt
drive and spends most of his time home eating, reading, watching TV,
sleeping may not bother with the surgury. Same for someone with risks
of other problems including retina detachment. People with only one
good eye because the other has diseases, retina detachment or amblyopia
are much more reluctant because if theres a complication in the good
eye they dont have the other eye to fall back. You can have
complications from cateract surgury that can make your vision WORSE
than it was with cateracts. I know one guy who ended up overcorrected
and induced astigmastim and other disortions in his vision. He said his
new vision wasnt any better than his old vision so he was unhappy. He
also couldnt wear glasses anymore due to anisometropia.
Lasik is generally reguarded as completely elective |
|
| Back to top |
|
|
Neil Brooks
medicine forum Guru
Joined: 24 Mar 2005
Posts: 1148
|
| Posted: Fri Jun 02, 2006 8:29 pm Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
On 2 Jun 2006 13:16:29 -0700, acemanvx@yahoo.com wrote:
| Quote: | Cateract surgury is both elective and a neccessary. Someone who doesnt
drive and spends most of his time home eating, reading, watching TV,
sleeping may not bother with the surgury. Same for someone with risks
of other problems including retina detachment. People with only one
good eye because the other has diseases, retina detachment or amblyopia
are much more reluctant because if theres a complication in the good
eye they dont have the other eye to fall back. You can have
complications from cateract surgury that can make your vision WORSE
than it was with cateracts. I know one guy who ended up overcorrected
and induced astigmastim and other disortions in his vision. He said his
new vision wasnt any better than his old vision so he was unhappy. He
also couldnt wear glasses anymore due to anisometropia.
Lasik is generally reguarded as completely elective
|
As always, I don't know what the eye doctors would do without you
coming along to clarify things. |
|
| Back to top |
|
|
Anon E. Muss
medicine forum Guru Wannabe
Joined: 22 May 2006
Posts: 136
|
| Posted: Fri Jun 02, 2006 9:09 pm Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
On 2 Jun 2006 13:16:29 -0700, acemanvx@yahoo.com wrote:
| Quote: | Lasik is generally reguarded as completely elective
|
Not completely, but I'm sure even this is up to debate.
Here's an example:
7 year old girl with the following prescription:
OD plano DS
OS -8.00 +4.00 x 090
or
OD plano DS
OS -7.00 DS
Cannot tolerate spectacles (e.g., due to anisekonia) and is contact
lens intolerant. Without proper intervention, the possibilty of
amblyopia, poor/non-existant stereopsis, etc. is high.
Someone like this I could consider *recommending* refractive surgery,
depending on the rest of the story (e.g., OrbScan, keratometry,
pachymetry, etc.) and examination results (e.g., BCVA, retinal
status).
If it was my eye, I would prefer the relative risk of refractive
surgery over almost certain amblyopia and astereopsis.
But for the vast, vast majority of patients, LASIK surgery is
completely elective. |
|
| Back to top |
|
|
acemanvx@yahoo.com
medicine forum Guru
Joined: 15 Nov 2005
Posts: 732
|
| Posted: Sat Jun 03, 2006 1:05 am Post subject:
Re: How do you select an eye surgeon for cataract surgery?
|
|
|
Anon E. Muss wrote:
| Quote: | On 2 Jun 2006 13:16:29 -0700, acemanvx@yahoo.com wrote:
Lasik is generally reguarded as completely elective
Not completely, but I'm sure even this is up to debate.
Here's an example:
7 year old girl with the following prescription:
OD plano DS
OS -8.00 +4.00 x 090
or
OD plano DS
OS -7.00 DS
Cannot tolerate spectacles (e.g., due to anisekonia) and is contact
lens intolerant. Without proper intervention, the possibilty of
amblyopia, poor/non-existant stereopsis, etc. is high.
Someone like this I could consider *recommending* refractive surgery,
depending on the rest of the story (e.g., OrbScan, keratometry,
pachymetry, etc.) and examination results (e.g., BCVA, retinal
status).
If it was my eye, I would prefer the relative risk of refractive
surgery over almost certain amblyopia and astereopsis.
But for the vast, vast majority of patients, LASIK surgery is
completely elective.
|
I think I mentioned somewhere about lasik being a good option for
anisometropia. However lasik is illegal if you are under 18. Thats
because your eye(s) are not stable, still growing and changing and also
you are a minor and can not consent. She will just either have to deal
with contacts as best as she can or wear glasses and patch the good eye
to exercise the weak eye so it wont go amblyopic. |
|
| Back to top |
|
|
Google
|
|
| Back to top |
|
|
|
|
The time now is Thu Jan 08, 2009 12:02 am | All times are GMT
|
|
Mortgages | Car Finance | Free Advertising | Loan | Bankruptcy
|
|
Copyright © 2004-2005 DeniX Solutions SRL
|
|
Other DeniX Solutions sites:
electronics forum,
Science forum
Unix/Linux blog
Unix/Linux documentation
Unix/Linux forums
|
Powered by phpBB © 2001, 2005 phpBB Group
|
|
FAQ
Search
Memberlist
Usergroups
Register
Profile
Log in to check your private messages
Log in
Forum index
»
Medicine forums
»
vision
