Retinal specialists have a fix-it mentality; they want to help improve patients’ vision. But there are a number of scenarios when operating may not be in the patient’s best interest — or yours.
“I think one of the strongest traits a surgeon can have is to know when to operate and when not to operate,” says Carol Shields, MD, codirector of the oncology service at Wills Eye Hospital in Philadelphia. She and other specialists interviewed for this article offered their best advice for when to think twice before proceeding to the OR.
One of the most important reasons for avoiding surgery is when a procedure has a low likelihood of success, says Sunir J. Garg, MD, a retina surgeon at Wills Eye Hospital. He was reminded of that recently when a patient with a chronic closed-funnel retinal detachment came in wanting to try to make things better. Dr. Garg says he wasn’t sure what the outcome would be, but he agreed to try to fix it.
“Within 10 minutes [we realized] that this eye was not fixable and I shouldn’t have operated on him,” says Dr. Garg. “Sometimes you do things because you want to help, but then you realize that the smarter thing to do may have been nothing. My former service chief, Bill Benson, MD, used to ask, ‘Is this case a 2 or a 4?’ He wanted to know if you were operating ‘to’ an eye or ‘for’ an eye. There’s a lot of wisdom in that question.”
In cases where patients’ medical conditions preclude their ability to go to the operating room, postponing a procedure may be in order, says Timothy G. Murray, MD, MBA, of Murray Ocular Oncology and Retina in Coral Gables, Florida. This includes patients who have uncontrolled hypertension, with severe diabetes, who are pregnant, or who are taking systemic anticoagulation drugs. “Current data suggest that you’re more likely to potentially harm the patient by trying to alter their anticoagulation status than by operating,” he says. Many doctors will try to get patients’ anticoagulation levels as ideal as possible before operating.
With pregnant patients, Dr. Murray often opts to wait at least until after the first trimester. If women are further along in their pregnancies, he may ask their obstetrician to deliver them at 38 weeks so he can get them to the OR. “We know that we can safely operate on pregnant women,” he says, “but we try to factor in relative risks not only to the patient but also to the fetus.”
Delays are also warranted if the patient has an active infection in either eye, even if it’s not the one to be operated on, says Marguerite McDonald, MD, an associate with Ophthalmic Consultants of Long Island, in New York.
RED FLAGS FOR SURGICAL DECISION-MAKING
Factor in comorbidities when making any surgical decisions, Dr. McDonald adds. Patients with significant ocular surface disease (OSD), for example, are not good candidates for multifocal intraocular lenses or the newer extended depth-of-focus lenses, she says. Those with OSD and early dementia who may take good care of their eyes now may not be able to do so going forward, even in the best of assisted living facilities.
“There are a lot of almost philosophical decisions you have to make and long discussions with the patient and the family,” Dr. McDonald says. “Sometimes they are hard discussions.”
Before heading to the OR, make sure you know what condition you’re dealing with, cautions Dr. Shields. Some eye cancers can appear like other disorders. “Think twice, think 3 times before you do surgery on any baby with endophthalmitis, because it could be vitreous seeding from retinoblastoma, or in any baby with total retinal detachment thinking it’s Coats disease, because it could be exophytic retinoblastoma,” she says. In those cases, get an ultrasound and look for calcium in the tumor. If that’s not helpful, get a CT scan to look for calcium in the eye. If all else fails, she says, “have your friendly ocular oncologist take a look.”
Also be wary of a retinal detachment up near the back of the lens that is not likely a rhegmatogenous detachment, as retinal elevation that high is usually a sign of an exudative process resulting from inflammation, Coats disease, or tumors such as melanoma, retinoblastoma, or diffuse choroidal hemangioma, Dr. Shields says. And think twice before you drain a choroidal hemorrhage or choroidal effusion because that, too, could be a melanoma. Diagnostic tools like an informative ultrasound or MRI can help identify a melanoma. You also can look at the sclera for sentinel vessels that sometimes are associated with melanoma. Again, if in doubt, consult an ocular oncologist to be sure.
Patient noncompliance is another red flag when it comes to surgical procedures, says Dr. McDonald. If patients don’t take any of their preoperative antibiotics or other medications, cancel the operation, she says, so you aren’t liable if the patient develops a postoperative infection. Children can be noncompliant when it comes to avoiding food before a procedure, adds Dr. Murray. “Kids can be sneaky. I had one kid whose mom turned her back in the pre-op area, and the next thing you know, he got a hold of Cheerios and ate half a box.” The operation was rescheduled.
Patients with unreasonable expectations also should make you halt, say Drs. McDonald and Garg. “If they say, ‘Can you guarantee that I will see 20/20?,’ then I say, ‘I cannot guarantee that you won’t be abducted by aliens in the next 5 minutes,’” Dr. McDonald says. Some patients, even when you explain the limitations of an operation, don’t want to hear what you’re saying, adds Dr. Garg. “If in the pit of your stomach, you feel like you’re going to regret operating on this person, listen to that gut feeling ... because those cases cause you nothing but heartache and grief later on.”
Finally, there are sometimes difficult patient personalities to contend with. Dr. McDonald has handled a range of challenging scenarios, from patients who inquired about her anatomy grade during medical school, to those who tried to covertly record their conversations, to others who yanked technicians by the ponytail to ask if they were next to be seen and disparaged other ophthalmologists she knew to be reputable.
If you have a feeling there’s no trust with the patient, pass on operating, she says. “If you sense a red flag, even if you can’t identify why you feel that way, there is a reason.” And beware of patients trying to force the issue, says Dr. Shields. “Don’t ever let a patient talk you into doing a treatment that you don’t believe in. Learn to walk away from the patient who is twisting your arm.”
OPTING NOT TO OPERATE
If you opt not to operate, be very careful about how you phrase it and be prepared to spend more time on the patient consultation, Drs. McDonald and Murray say. “If you have a real physical reason [for not doing the operation] it’s better than saying, ‘I am afraid you will sue me for no reason, even with an excellent outcome, and I think you should find somewhere else to go,’” Dr. McDonald says. If there are no medical contraindications, she says, “You just have to tell them the truth as gently as you can: I like you, I respect you, but I think we’re not a good match.” In those cases, she will make a referral to a colleague and forward records.
“When you look at somebody who knows something’s wrong and you tell them the best thing is not to operate, that’s not what they see on TV or read in books,” Dr. Murray adds. Patients can be confused or disappointed. Sometimes he will tell a patient he won’t operate now but leaves the opportunity for another exam and discussion at a later time.
Dr. Murray often receives referrals of difficult patients from colleagues, and he tries to take it in stride. “I look at this like a difficult family member — you know it will be difficult, but it’s why you’re there and it’s what you do.” The best thing to do in those cases, he advises, is to ask a colleague in your field to see the patient so the patient has opinions from more than one expert. If the ocular issue is not emergent, he’ll make sure to schedule one visit so the patient can get to know him and the office staff before scheduling surgery.
Make sure to document your decisions in patients’ electronic records. Dr. Garg includes a notation that he and the patient together decided operating would not be helpful. If your decision not to operate was due to patient noncompliance, make sure to note that, Dr. McDonald adds. Dr. Shields says she often dictates letters to referring physicians in front of the patient so they can rehear the information they just discussed.
Finally, the experts say, recognize your limitations. “Something I learned early on in my career is ... not all of us are good at everything,” Dr. Shields says. “If I see a condition that I feel is beyond my set of skills, I have no problem referring the patient to another surgeon who I think has a better set of skills for that condition.”
Dr. Garg provides patients with specific names and phone numbers of colleagues that he recommends so patients don’t have to try to figure it out. Even if the patient doesn’t take you up on your offer, he says, knowing that you’re confident enough in the limits of your abilities “goes a long way.” RP