Sometimes, it’s best to swallow your pride and allow patients to seek a second opinion.

During my medical training, my mentors urged me to practice with the following in mind: Never hesitate telling your patients that they should seek a second opinion. This advice was reinforced by another mentor, the late Barrett Haik, MD, former chair of the ophthalmology department at the University of Tennessee, and by my father, a clinical instructor in ophthalmology at the University of Toronto.

MY MANTRA

I have kept this advice close to heart, even though the medical and surgical retina practice I started after fellowship has been busy and rewarding.

For the handful of patients who I’ve encouraged to seek re-evaluation, I have asked H. Culver Boldt, MD, University of Iowa, who is more senior than myself and capable of a “judgment-free” evaluation, to provide them.

So, as my subspecialty practice grew — it’s located in a rural Iowa community — my conscience has been at ease knowing that help, if need be, was close. Over time, as you might expect, the need for second-opinion referrals decreased as my experience increased.

CONCEPT ACCEPTANCE

Retinal surgery is unique in that we are trained to accept that, in spite of proper and well-timed treatment, the disease may progress and further intervention may be required. We generally accept that concept and it is comforting to know, for example, that should a pneumatic retinopexy fail to reattach a rhegmatogenous retinal detachment, pars plana vitrectomy, normally scheduled for later in the day, would.

Despite this training, one case of aggressive-posterior ROP from my first year of fellowship has remained with me: In spite of well-timed and thorough laser surgery (this was before anti-VEGF treatment became a practical option), vitreous hemorrhage developed in one eye shortly afterwards and vitrectomy was scheduled. It was a lesson in how aggressive and unforgiving this disease can be.

Regardless, I believe I was destined to screen and treat those babies. ROP has been a kind of “legacy” pathology for me as my father, a comprehensive ophthalmologist, screened babies long before the current definitions of pre-threshold disease. During my fellowship, the neonatal service at the major county hospital in Memphis, Tenn., allowed me to screen well over three dozen premature babies a week and provide both laser and medical treatment for prethreshold disease to more than two dozen patients.

The inherent nature of ROP is aggressive and unforgiving. As such, I do not hesitate to ask for help, even years post-fellowship.

THE INEVITABLE CHALLENGE

Several months ago I came across my first patient, since my fellowship, with aggressive posterior ROP. Arguably, management of this unique form of ROP has changed somewhat since then. Regardless of a surgeon’s opinion on the use of anti-VEGF treatment in prethreshold ROP, the availability of these medications does play an important role in the algorithm of treatment. We should consider them in the appropriate circumstances and discuss them with family as treatment options.

My initial plan for this near-term baby was to offer bilateral injections of anti-VEGF medication and provide laser photocoagulation several weeks later when the baby was more stable and general anesthesia less risky. Because standard of care is largely determined by one’s geographic area, I heeded the advice of my mentors and contacted two nearby major teaching hospitals for advice on how they would handle such a case.

To my frustration, I learned that, in spite of managing hundreds of premature babies annually, one institution had never come across this particular condition. The other academic center had seen a handful of similar cases; they agreed that they would proceed with a similar plan to mine.

OVERCOMING DYSPHAGIA

Telling family about the use of anti-VEGF therapy in the setting of threshold ROP takes time and patience; it is a complex business. It is ironic that such a quick procedure can involve lots of time to explain the many long-term risks, as well as the better-known, immediate risks associated with intravitreal injections, in particular when associated with a much smaller neonatal eye.  Although I was confident in the treatment approach I outlined, I did recommend the baby be evaluated by the academic center experienced with this condition because the situation was rare.

Despite my experience performing laser photocoagulation on babies with more traditional forms of the disease, the family seemed concerned when I admitted that, while technically the two-step procedure is quite straight-forward, I had not performed it in this situation. Herein lies the complexities of doing what is considered best for the patient vs. what is best for me.

Approaching my facility’s neonatologists and asking for a transfer for a secondary evaluation was not easy. If it is hard to come to terms with requesting a second opinion, going against public opinion to do so requires an even stiffer spine. I explained the complexities of this patient’s unique situation — in particular, the not-so-insignificant possibility that, in spite of treatment, the baby could progress to permanent vision loss. I could sense that the team felt that transferring the baby, whom from their perspective was doing quite well, to the academic center was a disappointment.

While I sympathized with their view, I maintained that I promised the family that we would do all that we could to determine the best treatment plan. Ultimately this was accomplished, and I have no regrets in how the situation was handled.

As a physician, it can be difficult to appreciate that you are not the most important person in the room. It can be challenging to admit to one’s self that perhaps a second opinion is needed, let alone asking other well-qualified subspecialists who are directly affected, to understand that such a step should be taken. I am fortunate to have had mentors who instilled this ethic in me. I have a hard time imagining how I would have felt had I not done so in this particular circumstance and the outcome had gone the other way. OM

Brendan Girschek, MD, FRCSC, FACS, is director, Pediatric Retina Service at St. Luke’s Hospital in Cedar Rapids, Iowa, and team physician for the Waterloo Black Hawks.