 question today. I do want to just get a bit of bookkeeping out of the way. Please look for information on submitting and obtaining CME in the chat that will be posted throughout the meeting. This is a this a meeting in our ethics conference where we do encourage this actually is designed in fact for discussion and we we actually do not have a lot perhaps not more than 15 minutes total of actual presentations today. So as such given that that you all have are not able to unmute these are the ways that you can be unmuted. You can simply use the raise your hand command in zoom. You can also in the chat just ask to be unmuted or say ask to make a comment. We have an ability to make you a co-host so if you see that you're a co-host that just means that you know how freedom to unmute or unmute yourself your discretion. If you are asked to unmute Ethan gives you that permission then you'll be unmuted as long as as you speak until you remute and then you need to ask for permission again. So again if you feel like you'd like to make numerous comments we can certainly make you a co-chair. Medical students, residents everyone we do ask for your commentary and engagement. So in terms of framing ethics it's again worthwhile to review the four attendance of medical ethics autonomy beneficence non-maleficence and justice and this framework is what I can share a paper that outlines these four tenants and it talks about this concept of prima facie and essentially that means at first site at first space in Latin and what that implies is in the absence of conflict between any of these tenants of medical ethics you should follow and we are obligated dispositions to follow the the tenant right whether it's just autonomy only or if it's beneficence if indeed there's not conflicts with others however there is you know nary an ethical dilemma that we're going to face that won't have some conflict between one or two of these areas and with that as a preamble I'm going to go ahead and dive right in and introduce and acknowledge our presenters today Dr Arianna Levin will be presenting first she comes to us by way of wild Cornell Medical School she is a current PGY3 I would never steal her thunder and announce what her career plans will be so she can certainly share that with you at the beginning of her her case presentation next we'll go to Brad Jacobson he comes to us by way of UC Irvine Medical School he is a chief resident here most of you know what his next steps will be but again I'll let him tell you with all the excitement and zeal that Brad is capable of of what his next steps will be in his career and finally Han Gam Lee she comes to us by way of University of Michigan Medical School and did her residency at Northwestern and is currently our first year retina fellow thank you to each of you for taking time particularly before OCAPS to present to us us without further ado Arianna take it away thanks dr petty anyone waiting I'm planning to apply to glaucoma but today I have a case to share and then we can discuss let me share my screen okay so you should see a document that starts with 73 year old male at the top this is a case of a 73 year old man who had come into us with a past ocular history followed by optometry of cataracts and ocular hypertension in September he was first referred from optometry for evaluation of his cataracts for surgery and he was seen for this cataract evaluation in October on that evaluation his visual acuity was count fingers 10 feet in the right eye and count fingers at eight feet in the left eye his pressures are 25 which was typical for him there was no documented apd and on description of the cataracts in the eye exam both of his cataracts were described as four plus nuclear sclerotic one plus psc there was a view back to the fundus and it was clear enough for there to be documentation of a 0.5 cup to disk pigment modeling and the periphery normal vessels and even a nebis in the left eye he underwent cataract surgery in the right eye first and was seen for his post-op week one visit in November and he commented at that visit the surgery didn't really help at that visit his visual acuity in the right eye was still count fingers at 10 feet the left eye was unchanged his pressure had come down to 13 and there's still no apd and then in the assessment and then plan at this visit the comment was the patient would still like to move forward with cataract surgery in the left eye and our referral was made to neuro ophthalmology after no improvement in vision of the right eye he was seen later that month with neuro ophthalmology and on further history at that visit he said that he woke up with vision loss in august so a couple months before his cataract evaluation he had had neon green and lavender flashes a few weeks prior to this vision loss in august a couple years ago he had been 2025 he does crossword puzzles and had been doing crossword puzzles until this acute event in august he wasn't seen in august at that time of the event further workup was done he had an MRI of the brain that was normal he had an ERG that demonstrated optic neuropathy and then he had an extensive lab workup for optic neuropathy that did not reveal the etiology so at that point the comment was there was a discussion with the patient his wife and his son that we don't expect the second cataract surgery to improve vision but we'll leave it up to them whether to cancel or not he decided not to cancel and felt that he wanted to try anything at all that might give him some hope for his vision and then he was seen after his cataract surgery in the left eye at the post-op week one visit and he said there's no improvement this is just like how the right eye was after surgery his visual acuity at that time was count fingers at one foot in the right eye and count fingers at two feet in the left eye he also asked if he could trial steroids and the comment at that visit was that he was counseled that we will not trial steroids without a diagnosis so in the blue box i have a few questions for a discussion but we can take this where we want to so the first question is should the patient have been offered the option of proceeding with cataract surgery in the left eye and the second question to think about is how or whether refusing the patient's request for a trial of steroids is different or similar to refusing the patient's request for cataract surgery and now open it up thank you ariana again please either raise your hand or actually the chat would be the preferred method if you'd like to be unmuted we definitely would like to encourage some discussion and conversation in this we are broadly going to be speaking about when a patient has a desire that has some sort of conflict with the physician this is one case outlying several several issues so we talked briefly earlier about beneficence and non-maleficence and oftentimes as we're looking at the conflict between these two we're trying to make a decision on perhaps the overall net benefit now we do this you know within our own minds when we're thinking about entering into a treatment or a surgery for someone is there a net benefit do the benefits outweigh the risks in this so that that is an entirely uncommon to us in the way that we go about our clinical decision making however we all have been in situations where the patient may have a desire that could be in conflict with what we think is right and so in addition to comments about Dr. Levin's case and offering commentary on her questions that she's posed would also welcome additional cases you have experienced as you think about this where perhaps a patient's desire may not may have conflict with what you think is the right next step for some reason or another so we are going to allow for a little quiet here that's fine you can use that to think about these issues comments again raise your hand if you'd like to comment well for the most part be making people co-chairs so you can uncomment at will but we definitely would like Roger Randy we'll go ahead and make you co-chairs and you guys can unmute yourselves so I'll start out obviously these these are tricky situations and I think that we have to be totally honest with our patients where the evidence is overwhelming that there is not going to be any improvement in association with cataract surgery that this isn't something that that makes sense but we have to be careful about assuming that we we we know everything about it so I mean I think if our knowledge basis is truly unassailable I think that we let people know that there are there is potential risk from doing surgery and doing something in which there is no outcome but I think we need to be extremely certain about that and I'll give you one example this is actually the wife of a of a very famous physician probably one of the most famous physicians University of Utah has ever had and she presented with a super dense cataract that she'd had and she was hand motions vision and I and and that she was pretty confident that that you know that she'd had a pretty dense amblyopia history was a little uncertain and I you know said well I don't think we should do the surgery and she agreed and then finally we got to a hyper mature situation with her cataract where we had to take it out and she was 2020 and she was able to fuse and she was delighted but furious that she'd been told forever not to have surgery and I just took it at history and there were things we could have done even then to kind of realize that she had more potential and so I just we just I think we have to be you know cautious where we're not quite certain but this one is I think pretty clear that surgery is is unlikely is unlikely to help but if we if we're not certain and the patient is very demanding I mean the upside is high enough that I think we need to be flexible thank you Dr. Olson Dr. Harry feel free to make your comments yes I agree with Randy that these situations can be challenging I think in this case it's probably a little less difficult than other situations this patient had a dense cataract so you can certainly say well discuss with the patient give them all the facts you know your other I didn't do very well the ERG showed probably some optic nerve problems so the odds are you won't see very well but it's kind of your choice and as long as you're presented with the those facts and you know unbiased way to make the final decision I think it's harder when you see patients with minimal cataracts I seen a number of patients referred that outside ophthalmologist told them oh you got a terrible cataract you can't drive anymore from the surgery tomorrow they come and you've sort of got to talk to them the other way that it's not that bad you know you can probably wait for now so that's that's a harder situation but in this case I think it's you know reasonable to at least offer the patient you know the option and as long as they understand family I'd probably get family involved too be sure they're on board that you know the surgery may not do much but with the dense cataract maybe there might be some as Randy's case about a woman with dense angliopia that ended up seeing pretty well sometimes you're surprised when when that but it's done yeah a couple of points again Dr. Olson's point about you know there is an unknown in this particular case particularly with cataract surgery and what visual potential can be and that's something that frankly in many ways we don't know and you know Dr. Harry well stated you know the the challenge of of perhaps the expectation of the patient not really meeting what we think medically is is possible. Dr. Hoffman you are unmuted. I just want to say I think it's important to acknowledge what the patient is really telling us here and that the patient's desperate to see better you know and to acknowledge that and say that we're willing to do whatever we can to help accomplish that within reason but you know cataract surgery is just another way of trying to accomplish it and it may not be the appropriate option so that the patient understands that we're on their side we're not just cutting them off saying you don't get surgery we want you to see better and that tends to go a long way. Thank you Bob that's one of the Dr. Hoffman that's one of the things that that has struck me recently if you have someone coming in with perhaps a you know a central scatoma from AMD for instance kind of mild to moderate cataract and for them really any improvement in vision might make a real significant difference. Dr. Stagg I believe you can unmute yourself go ahead. Yeah can you hear me? Yes. Yeah I really liked what you just said Dr. Hoffman. When you think about those I really like the the ethics framework the four those four things um what's hard sometimes is there's kind of gray lines or blurs where you're like you know there's a balance between those but one of those four that I feel that I if you had to choose one that you really liked I really like the principle of autonomy and it kind of goes along with that and I think that I feel like that's something that we can take we can take control of ourselves. So for example I think that if you take the time and talk about the the good that comes from it talk about the potential bad and then I really believe that patients can have autonomy and that they appreciate that and deserve that and so I think for both of these questions I think both doing the cataract surgery or not doing the cataract surgery and doing the steroids or not doing the steroids could be appropriate if if you if the patient understands and if the patient's making that choice for themselves and I think that that also kind of like Dr. Hoffman was saying then they can feel they can know that they've done everything they can to see or they know that they don't want to take that risk and then sorry one other thing about the justice one because I I ask myself that all the time too um I'm not saying anyone did anything wrong in this case but sometimes we're influenced by what happens for ourselves so we get paid for cataract surgery but we don't actually get paid to get people's steroids and that's just something that I that I keep in my mind am I being influenced by financial incentives for myself? Thank you for both of those comments and I think always you know introducing the elephant in the room in terms of you know payment structure in the way that our financial model is is important and how that may or may not influence decision making. So you again made a comment as well uh Dr. Stag about autonomy right and patient autonomy being able to have some control over their care and you'll see in the kind of next cases there's also an element of our autonomy right and our ability to to perhaps make the decision that we feel is best that will be in conflict uh so we will uh Brad Jacobson why don't you go ahead and queue up your screen share? I do now that we have our sufficient quorum I do want to acknowledge Dr. Eileen Wong who's not in the Zoom today she had a conflict this entire ethics conference is actually her brainchild and were it not for this conflict she would be she would be chairing chairing this ethics conference so I would ask if you do see her just uh thank her uh for this really thought provoking discussion Dr. Jacobson take it away. You all see my screen? We can see your screen and audio is good. Awesome okay so um yeah thanks for the introduction Dr. Peddie earlier on um yeah for those of you that don't know already I will be headed to DC actually the only one in my class that's not leaving Moran so I don't really know what that says about me but I'm excited um but uh I am going to be presenting a case that I was involved with kind of peripherally throughout the whole thing but I initially saw the patient of course um on 4 at 4 p.m. on a Friday afternoon as it usually happens in Dr. Barlow's clinic and so um she's complaint uh she came in with left eye rejecting is what she says she's a 74 year old female with a history of two previous pks initially for care to conus followed by graft failure um two days prior to the presentation the patient felt that her left eye was just dry not really painful she presented to a clinic in Idaho where she lives where they removed two sutures and started her on Durazole. The following day so this is one day prior to presentation at Moran she woke up with very blurry vision um she presented to the same clinic where they taped the eye close and placed the shield and then the the following day which was actually the morning of presentation at Moran the pain increased and she presented again to the clinic. Per the clinic notes in Idaho she had left eye uh graft rejection with perforation and ophthalmitus rapidly worsening panophthalmitus graft rupture slash dehiscence that was exactly from their note and so sorry about that um when she saw us her on physical exam in the affected eye she was bare light perception unable to really visualize the pupils and she was in a significant amount of pain so um she wasn't really even able to move her eyes. In the right eye she was seen 2060 and can pinhold to 2040 and um so I actually have a picture of what her eye looks like sorry for those of you who are a little bit queasy but I thought it could add to the discussion a bit so you can see she just kind of got diffused erythema on that upper lid brow and cheek she's got perulent discharge she's has severe injection um and subconchine a completely opacified cornea that prevents view um into any other ocular structure she had some sutures inferiorly but once again it was a difficult view and a complete hypopia um of note she was seidel negative um so of course in these situations when we don't have a view to the posterior segment we perform a B scan the B scan did not show any vitritis uh but did show some diffuse curatal effusion um and just to throw some social history in the mix she recently had a husband who passed away of COVID I think it was about three months prior and was terrified of hospitals she currently lives in Felt Idaho which I google mapped is about 281 miles away from Salt Lake four hour and 11 minute drive uh the best corrected visual acuity in the impacted eye that we have on record is 2200 and that was in 2016 she was lost to follow-up her life goal is to spend as much time with her grandkids as possible and her wish from presenting with us was just to take the eye out and so we uh our assessment of her 74 year old female with a history of keratoconus that is close to pks presenting with perulent and not from minus of the left eye so we consulted retina per their notes they would not recommend a tap and inject given no vitritis and definite risk of introducing pathogens into vitreous cavity and given bare light perception guarded visual prognosis and high risk of progression of infection the discussion discussed option of enucleation with patient and she was in agreement um there was a lot of people involved in this case so we also consulted cornea uh discussed treatment options with patient and two sons uh recommended aggressive treatment with topical and systemic antibiotics and then reevaluation and then of course we consulted our plastics colleagues uh who wanted the patient admitted to hospital for pain control start topical vancomycin and tobermysin every one hour and recommend IV antibiotic coverage with gram positive and gram negative coverage and then of course frequent checkups on her on a daily basis hospital course so she had worsening eye pain every single day she actually developed pretty severe constipation and nausea secondary to dependence on opioids for the eye pain her physical exam was not improving on the IV antibiotics and topical antibiotics we had discussions with her and her two sons every day about the implications of evisceration and enucleation and patient adamant that she wants her eye removed she had good understanding of this information very very good insight and so um she ended up undergoing an evisceration seven nights after admission to the hospital and the specimen contained in quotes disorganized disorganized intraocular contents and so that's it for my patient presentation just some discussion points that um I thought could fuel the discussion of course you guys can take this anywhere you'd like but so we had several long discussions with different healthcare providers the patient was adamant that she wanted her eye removed she was pretty consistent throughout every single conversation however she was admitted for IV and topical antibiotics instead the patient had good insight and family support so should we have done the surgery earlier and I'll kind of leave it at that thank you dr. Jacobson we'll we'll just leave those questions up here for about another minute and then you can stop sharing after that uh you know boy a lot going on love to hear if if if they're available unmute dr. Lynn dr. La Rochelle dr. Crum any of you with comments perspectives that can help add to this I see dr. Olson you're unmuted if you want to go ahead make comments sure uh yeah these these are these are particularly tough cases and I I know our reluctance to a nuclear reviserate when we've got any chance that there might be some visual potential but I've I've talked to a lot of these patients in this kind of situation and and uh I I think that uh it is not uncommon that we we do prolong their agony from what an outcome that's probably uh gonna happen uh and so I think we should be willing to listen so and talk to them you know in this particular case all those corridors certainly suggest and the other exam is is it probably even though it was Seidel uh negative the time that there probably you know was a breach uh that the suture coming out in a failing cornea and there probably was a breach uh of the incision um it's probably filled up with fibrin and all that horrible mess that we're seeing in that eye and that explains the corridors for instance and and uh you know I in situations like that I've I've taken the the the route I said well let's let's just let's get a culture right now let's get some antibiotics and let's let's reassess but rather than you know reassess uh in in uh you know in in seven days or so you know make a decision that would give us 48 hours something that's a reasonable period of time and uh if it's a really bad organism and clearly there's not much of anything changing uh then and I I think we we should be prepared to go ahead and step in and relieve them of their agony where it is it is both clear that the prognosis is awful and the pain and the problems of being in the hospital are very real for somebody that age so I'm not saying you necessarily do it immediately but be be pretty willing to throw in the towel when it's quite obvious that there's not much to be gained and lot to be lost for somebody who's suffering thank you Dr Olson uh you know you bring up uh one of the comments that struck me is uh the you know you you had written that she had good understanding uh and and I wonder I'm not sure if um Lisa Ord is available to unmute yourself we certainly can if you can raise your hand or let us know in the chat you can be unmuted uh because that's something that comes up for me a lot um we know how complex these issues are and they're hard for us to make decisions when we live in the space and are doing this all the time and thinking about the ramifications and seeing blind patients and seeing patients with poor outcomes and seeing patients who have gotten better and and kind of you know as we try to make that determination of how much the patient understands you know Dr Stag yet to your point how much autonomy can are we able to give um I'd love to hear some comments on that and it looks like Amy Lynn um I've just asked that you be unmuted if it's okay Amy let's go ahead and let Lisa Ord come in first and then we'll go to you Dr Lynn right and I think that the issue um really comes in to do they understand all of the ramifications of what they are asking for and is there any other um route and the fact that she was admitted for IV um and topical antibiotics to try to to save um anything I think you know even though she wanted the eye out and a lot of times people in pain patients in pain they want something that right at that moment that they may not want later on so yeah it becomes a real balancing act of you know autonomy for the patient and also what is going to be right in the long in the long run thank you that's that's such a great point I mean perhaps it is just I need to be out of pain at this moment and that is the answer stirring them in the face within their framework uh Dr Lynn so um I'm in agreement with um kind of a common step in May then this is something that unfortunately doesn't um it happens pretty you know not not too infrequently in cornea a patient coming in who's PK with overwhelming infection so I again if the patient is in agreement and we see that there's just a very very poor prognosis for any useful vision in the eye it definitely would be reasonable to intervene with nucleation nor visceration much much earlier again with all the discussions that kind of come into play um of course if this was a another patient that's you know just coming in with a mild say graph rejection something that's very easily treatable and the patient's saying they want their eye out then of course then we have to say no this is not the right treatment we can get you better but in this particular case with the kind of overwhelming infection and fact that this patient lives very far away from you know major medical center it and understands all the ramifications has family support then I fully support the patient and and moving forward with her wishes sooner thank you Dr Lynn again great great perspectives and and and it it also touches a little bit on something we deal with perhaps not on such a high-stakes basis but we deal with on a regular basis is um you know the referral between specialists particularly in our building where we have so many sub specialists and you know when there is you know potential just just disagreement on the next best step right perhaps they meet with you and say this is reasonable and nucleation is a very reasonable step whereas retina feels look we haven't even maybe even plastic feels we haven't even given this a chance yet to heal and and now we're in a situation where the patient has expressed a desire we have providers with common goals but yet different you know next step pathways that they are potentially suggesting and and I think the right person to resolve all of these questions is probably dr staggs since he brought up the autonomy piece and he said it was his favorite because again now we're dealing with autonomy of multiple again multiple medical professionals dr staggs you're welcome to unmute yourself or raise your hand i can oh there we are and let me just make sure all right you're able to unmute so uh yeah no i i really thought you made a great point the each of those those four issues has something that complicates it and makes it challenging and i think the big challenge for patient autonomy is understanding so i thought i thought that was a really good point um and then the autonomy of different providers my my thought just thinking through this case as i was thinking about the residents who are often uh in these complicated cases stuck in between communicating with different people and communicating with the the uh the the patient the provider is trying to verify understanding and that that can be really challenging so i was wondering if some maybe one of the residents who was who was involved in in there like could talk about uh Dr Jacobson perhaps you can make a comment as i have gone on and seen more patients that we followed in in the continuity resident clinic uh it it it's not lost on me at all how vital the resident role is in being that that that one single common denominator throughout all of the care uh and and how this this can certainly be a confusing labyrinth um you know just they very well may meet eight different doctors in two days you know for these complex situations Dr Jacobson why don't you go ahead and just make some comments from the resident perspective and then next we'll go to uh hon gem lee for our final case presentation yeah i'm happy to talk about it i was actually be interesting i don't know shon collin if you're on he was the consults resident i believe at the time and um oh he would be i'd be willing yeah so let's uh ask shon to unmute because he actually talked to them quite a bit nice all right shon you are asked to go ahead yeah hey there um so yeah i think you know on on on my in that particular month of consults this i had this situation and in several cases where there were all these different subspecialties involved and it is a very difficult place to be in especially when there's difficult or different um you know the same data is being observed by different subspecialties and you're getting sort of different messages from all of them and there's really uh i mean the what ended up happening in this case that i thought was helpful was um an email chain that sort of involved all of the uh involved parties that finally got all the people on the same because it's it's it's as a resident it's really impossible short of getting the um attendings who will be making the ultimate decisions uh together and and having them conversed it's it's kind of impossible to to move forward with it it seemed to me um and then one other thing i was thinking about that that just made this case a little bit remarkable and i too was kind of peripherally involved i really only saw the patient a few times um but but i was the the council resident but every time i went to talk to her she was very aware of her desire to have the iron move potentially just reflecting her acute pain um and she had a lot of really good insight into that um which which you know just to sort of support what we've been saying that that she did have very good insight throughout the process um and and uh and so yeah it was it was a it was a difficult um situation but i think once we got all of the providers together in in one place that's when we were able to move forward i just uh would like to make a comment to follow Sean's um thoughts so you know from this case i do i i'm really glad that dr stack you brought up uh uh the concern for the resident involved in complicated case like this because i do really sympathize with how challenging it is for for our counseling resident because a one they are still in early training for for pgy2 and and three they're still in their early phase of training and for them they're still learning and a lot of the information coming from different subspecialty they are you know processing and trying to decide which one to listen to and which one is the ultimate correct answer and there's no ultimate correct answer and and but then as you know fully train md and you know halfway through their resident's training have enough insight to know maybe what is the best for the patient but sometimes that doesn't align with you know the what is you know dictated to them and for them that's like a lot of challenging a lot of conflict and they have to go back and forth between different providers and i actually was involved in this case uh very early on and uh and i was involved throughout throughout the course of the discussion and it was also very difficult for me because as a retina fellow i am not the one to remove the eye i'm not the one to make a call on that the corner is fail here and that rely on the corner specialist rely on the aqua plastic specialist but then i can see that you know we've been waiting around for a long time and i can see that there's the resident struggling to to try to like you know who do who did they go to and i think that thanks brad for like creating that email exchange because that really you know force all of us to have a conversation and then when we see when we finally see that thing is not moving that somebody had to speak up and hey we'll have to do something and thankfully in the end everybody was on the same page and in the end the patient was happy with with the final decision but uh that just brought me to the um the next question is that you know i really hope that this kind of case doesn't like repeat itself over and over again for the resident because it's a very very time consuming and stressful situation for even for me to watch and i really hope that there is a some kind of protocol that the resident can follow to help guide them to better facilitate or coordinate this kind of conversation to make things move forward in a respectful and effective manner for both the patient and all the team providers all the providers involved in the patient care and i think i i was actually gonna email dr teddy because you are the program director and you are ultimately the boss of the residents and i hope you're responsible to to make that kind of workflow feasible for them so i hope that there will be something in place going forward yeah i i sincerely can't thank you enough for that comment uh it is so important that we always have an eye to doing better than we currently do i know uh teresa long has her ears peaked up right now she will be uh staying on with us as an academic fellow and really um you know our task shared task together is working to improve the consultation service and in particular this coordination together so uh dr hartnett uh is unmuted we'll have her make a comment and then i'll make a brief comment and then we'll go ahead and go to your case uh dr lee dr hartnett thank you um and great discussion and i wanted to um talk about cases like these over the years and uh even as a new you know as when i was a more junior faculty member and even as a resident or fellow uh what i found you know we're trained i'm trained we're trained as physicians to sort of take a certain approach with the patient and sort of have an understanding about what's going on with a path of physiology and all in a situation um and sometimes i found it very helpful then in fact i often find it very helpful to bring on other team members so we have a lot we have lisa ward and amanda and her team who can go in and talk to the patient and have a different perspective and even get more information about it uh sometimes i actually reach out to risk manager because like for example if there's a disconnect what i'm saying to a patient just doesn't have any response i'm probably missing something i'm probably either missing something that i don't understand that the patient has a question about i may not be using the right vocabulary and sometimes that can be very helpful so um i just wanted to bring that up so that the residents and fellows don't feel like they have to make the decision or they have to find something we do have other you know really skilled professionals who make up our health care team to do the best for our patient so i just want to thank you uh dr hartnett so well said and and so so for those of you outside that that may not know um dr lisa or is a phd she's a licensed clinical social worker she's the director of our patient support services and um you know i think it's worthwhile uh dr or if we just let you and meet yourself for a moment um just any additional comments before we get to to uh hung emily's case um yes absolutely we're always very willing to to give our um our take on where the patient's coming from um and i know that you guys have so much on your mind about medical and um the physiology and all of that other stuff that that um sometimes the emotional components that make up a big deal of all of our decisions um they can kind of get overlooked sometimes and there may be something that um we can shed some light on or at least help you feel better about the decisions that you are making thank you um sincere thank you dr all right uh hung em take it away you can screen share and present your final case for discussion okay uh okay can you see my screen just want to confirm yes audio is great all right so we're flipping the sides here um you know brad is presenting something that on the case where the patient wants something but there's hesitation um on the the surgical team or vice versa um but but this is different in the sense that like you will see okay so this is 40 year old women and she has double type two since age 13 and she suffered multiple and organ damage from poly control diabetes so she's not a very healthy person and uh she initially presented to the retina service in two years ago so January 2019 and at that time she has a pd on both eye and the left eye had has a tachalum tachalum macular off detachment for over a year already surprisingly at this visit the vision was still 2060 in that left eye with the mac of trd and so then um she um uh we saw for surgery but it didn't happen for for five months and at this time her vision declined to 2400 so she and they went a bit trapped to me laser and gas in the left eye and her post-op recovery was not optimal vitreous hemorrhage her vision never really recovered and then uh two months later she came back with still vitreous hemorrhage that didn't quite clear and there was a recurrent tracional retinal detachment now with pvr that was visualized on b-scan so at this point vision was like hand motion like perception so then she and they went the second surgery which was vitroctomy, lensoptomy, membrane peel, laser and silicone oil and again her post-op course was also very stormy she has post-op eye proliferation up to 50 there was ac fibrin there was concern for poor player block however the patient didn't want an lpi and around this time vision was lp hand motion okay and then she came back uh the next month now she developed a new uh macular involved giordi in the good eye the right eye and the left eye from the iop spike and inflammation now has a purple membrane that completely obscured the view to the back of the eye and uh so you see that there is a gap of of her follow-up here so from october 2019 she did not come back to she did not seek care for almost a whole year later so after her second surgery she was very upset very angry with the moraine eye center because of her suboptimal post-op recovery she did not recover she only lose vision from her perspective from her perspective it was our fault the surgeon's fault so she didn't follow up she no show to her appointment and she finally came into triage um in july 2020 that is about uh nine months later because of left left eye pain uh nothing uh and she specifically request not to be seen by the retina surgeon who performed the first two surgery and uh so she saw she saw uh attending in triage clinic and then i can't really figure out why she's having pain um her pressure was okay on eye drops and there's no view to the back because there's just that white people in membrane that obscure and uh the thought was that maybe she could benefit from a yak laser to remove that membrane so she was referred to uh glaucoma specialist for for that procedure and of course you know we know that that part shouldn't be done anyway because of the oil it would just make a mess so dr b was considering performing a secondary iol and silicon ore removal but that will require combined surgery with retina and the patient doesn't want to be seen by the retina surgeon who operate on her eye the first two time so she was sent to a different retina specialist dr c here and so at this time the plan was for okay we're going to try to go in remove the oil remove the syndicate remove the membrane and put in a secondary iol uh however that didn't go through because she again disappeared for reason i would assume that's covet her other health care problems so she disappeared for four months and uh and she stayed that no one called her to scare the surgery there's no evidence of that um and so at the last visit this is end of January early February and so you know her right eye now has chronic back up trd 21 50 in the left eyes you know as i have said a failure white people membrane balcony view vision is hand motion and it's been hand motion since the second surgery so um you know she continued to refuse surgery for the right eye which is the eye that has any potential if any um but and but instead she insists on going ahead with surgery for the left eye and so just want to summarize the course of the left eye so that we can have an understanding of an appreciation why this is a challenging you know decision so it had gone to surgery and both surgery were her post-op recovery was not optimal she never she never get the vision that she was you know satisfied with um and she's hand motion right now so this is just uh so however because of the patient insistent we are planning for this so it would require retracting means silicone or removal to nickel lysis stuff in their iol and this is just a summary of her vision so that you can have a appreciation why we think that visual potential in this left eye is so limited or poor and probably she can probably see better than hand motion so the 2400 here is uh basically before the first surgery and after the first surgery all we can get is hand motion like perception hand motion okay and one could argue that always sees hand motion because it's a fake because the silicone oil because there's a white cube membrane um but we need to remember that after her second surgery she has iop spike and fibrin all that so it's not just her retina there's also her nerve that is likely involved um so the question is that should surgery be discouraged for the left eye you know should we give in to the patient or should we discourage her so uh thank you again and i think again just because of the complicated course i just wanted to clarify one piece um the the medical providers felt that surgery for the right eye had potential benefit to the patient and and did question whether or not there would be any benefit to the left eye and yet the patient did want the left eye surgery is that correct okay so the you know the kind of age old question that we we started to face longer we're in our careers is you know when do we not operate when when is the right time to no longer um you know take another stab at um you know no pun intended um at at you know doing surgery on one of these patients doctor also i'm glad you're unmuted um this is not a simple straightforward one by any means yeah um i uh you know there were some simple things that we used to do uh when when i uh worked with uh herb kaufman he uh was known for someone who would often operate and this is way back when things were much less advanced particularly retinal surgery so we're talking ancient ancient period now 45 years ago um is that uh we we would often try to assess potential uh i think a little more than you know than than we do today uh to try to decide whether what there was a shot we there were there were there were uh things we would do such as uh what what he called a light field i don't some people i think have forgotten some of these old little tricks but uh patient looks straight ahead you shine a light out of a specific quadrant and and the rapidity with which they'd point to it uh correlated amazingly well with uh you know better than expected outcome in these really horrible cases um the other one would be to just uh blink blink the light straight on and then and then tell tell you tell you when they could see it and uh it was amazing how you could actually chart out a pretty good visual field this way on some of these in-stage patients and it was pretty obvious when they'd lost a central visual field say for advancing glaucoma and this would be a setup but this person would have lost a lot of additional vision from elevated pressure with that pupil remembering you know we'd say look we just don't see there's any potential but where where they would have a a good light field and and a good rapid projection of light even in some of these in stages we do reconstruction and had some miraculous outcomes with some people going from their only eye you know uh what was just projected as just you know light perception you know to getting 2080 2060 results and and i i think that that you know there's things we can do to try to ascertain but if clearly you you do a light field on a person like this and the and the central field is gone then then you know the telepatient i just don't see that there's any you know reasonable reason why you're going to get any return of vision and uh i think it's likely in this case that the odds of getting a good outcome are extremely slim but it's just it's it's uh you know there are other other simple things we can do and and it's it's an old art that i think people have forgotten um thank you dr olson dr laura shell why don't you kind of go ahead and make your comment and that will be either our last or we can take one more comment if anyone else wants to be imbued and then we'll do a wrap up so we'll do actually it looks like teresa long so we'll do a dr laura shell dr long and then i'll do a wrap go ahead dr laura shell so i think this case is complicated for several reasons that we sort of already touched on one of them is expectations from the patient for outcomes and um it sounds like you know you're maybe telling this patient that we think the outcome isn't going to be good and they still want to pursue surgery which goes back to autonomy right but then when they have the surgery and the outcome isn't good then they're blaming the surgeon so i think there's different parts here at play that make it an extra complicated scenario including the the issue with compliance so that can further complicate sort of the um the physicians i think willingness to go ahead with a surgery that they may think it's futile to begin with um knowing that the patient if it doesn't turn out well they might blame the surgeon and if the patient isn't doing their post op drop so they disappear again they could have a potentially much worse outcome and then it feels like it falls back on the surgeon again so um you know this is this is a just a tough one in general and it sort of lies between all the things we think about with not wanting to give up on a patient and have that that patient feel like we are doing every possible thing even if they're just getting another little glimmer of light after surgery they may feel like that is worth it whereas um like in that first case we were talking about doing a cataract surgery or doing a trial of steroids um don't have that terrible outcome potentials whereas maybe there's more to gain whereas this type of surgery is much more involved if it's an IOL exchange and oil removal in someone that's non-compliant and they could have hypotomy afterwards it's just the risk benefit ratio feels different especially in a patient that may not be have the insight that that some of the other patients that we were talking about do so actually Dr. Petty I have one more slide I need to go through before we wrap it up so I'm going to show one more so um so the so another layer of complicity to these cases that the patient is does not have insurance and it'll be out of pocket for her so the cost of the surgery is estimated to be around 25k so financial assistance is the requested and the surgeon would have to write a medical necessity letter for her to get this so then my last question is the cost matter and then I you know for me that question came to my mind and I caught myself like should I even ask that question because that's not fair for the patient to even think about costing the situation and there is something in the AMA code of medical ethics that kind of answer my question here is that although a physician have an obligation to consider the needs of broader patient populations within the context of the patient-physician relationship their first duty must be to the individual patient and when I brought up the cost because in my mind I said $25,000 that is what you can provide like 20 cataract surgery to 20 patients versus for one case like this that may not get her vision better than hand motion so that is the complexity point here that maybe you guys can agree or not agree with this statement here you know thank you for introducing this it touches on so many and particularly justice of course is is one of the tenants that this particularly points to but this boy this is an entire additional one hour discussion one thing we've learned about zoom the worst thing you can do is ruin a great discussion by going long and having people drop off Teresa I'm going to give you an actual 30 seconds and because I guess I've been named as your boss I can cut you off at 30 seconds and then we'll have our final wrap up okay so the first thing that I thought about was a lot of times when we don't recommend a surgery or we say that there's really not good visual potential for a patient and we were recommending we're not recommending doing something I think a lot of times the patient can feel abandoned and especially in a lot of these cases where there's views on one side or the other I think it's really important to have the patient know that even though we're not recommending something we're still here with you and we're still here to care for your eyes that's one two I think the relationship of time in a lot of these cases was really interesting so a lot of times as a referral center we're sent patients and it's our first time getting to know them and they already have a very complex situation and so it even though particularly in the second case we did potentially prolong the suffering of the patient by prolonging the suffering it gave us more time to assess the consistency and her understanding of something to give us more information to make the right decision it's a very different case oftentimes when you've had a years of long of a relationship with a patient and you know them and you understand their values versus just meeting someone for the first time. Dr. Long those are two beautiful comments I'll ask you to kind of put your third in the chat because people will have to get off right at nine and I do apologize for interrupting there I'm going to add one more thing to the chat again Eileen Huang really deserves all the credit I've actually just posted in the chat both her email and her cell phone so if you would all mind certainly residents since I'm your boss I can command you I guess to text her right now and just say thank you for this FX conference and anyone else who enjoyed the conversation I think I would certainly warrant an acknowledgement thank you to her via email certainly and with that let me go ahead and people do need to leave they can Dr. Long why don't we let you finish up your last thought you were so articulate in your first two let's go ahead and continue on that train as we sign off final words go ahead and then the last one the last pearl that I thought of is cultural differences so there's a really wonderful book that I read in an ethics class in college called the spirit catches you and you fall down it's a wonderful wonderful book and at the end of the book after you listen to the story of this young Hmong child who has seizures and her parents understanding and the care between the medical system and cultural differences there are eight questions that you can use to assess the patient's understanding culturally and understand where they're coming from with their treatment and so it's a really wonderful book if you haven't read it but the questions are actually quite useful when there's more challenging situations I find that more questions are also helpful and then Dr. Long if you can get us that those questions we can actually send that out to the group in follow-up thank you everyone Hong Emily Ariana Brad this is this is really exceptional thank you and was very enriched and the challenge would be to think of these four tenants in the next couple of days and how they are interfacing with you and your patients in your lives thank you everyone have a beautiful day