We’ve all been dealing with COVID-19 for what seems to be an eternity, so I thought I’d offer a diversion. Let’s look at a couple of controversial subjects in ophthalmology that affect us all.

TREATING FRIENDS AND FAMILY MEMBERS

The AMA has published a code of medical ethics position that strongly discourages treating family members and close personal friends. Only a small minority of doctors are AMA members anymore, but the association still has an excellent point. Treating someone close to you does have its downsides. These include your own feelings influencing your professional judgment. You might overlook “personal” aspects of the history. Those close to you might have a condition that requires pain management.

On the other hand, I’m pretty sure if I took a poll, most of you perform eye exams on your own family members. I’ve done refractive laser surgery on all three of my kids, and I know plenty of you who have done the same. If I developed a serious eye condition, quite frankly I’d rather my son be the one treating me. No offense to the rest of you, but I’m certain he’d leave no stone unturned. And, if anything seemed out of his expertise, he’d quickly refer me out.

BILATERAL SAME-DAY CATARACT SURGERY

We usually point out the risk of bilateral endophthalmitis in cataract surgery, but a 2017 study by Pershing et al, showed current rates down to 0.04%. So, if the right precautions are taken, the chance of bilateral endophthalmitis are quite rare. In my own community, I’ve witnessed complete blindness in one eye from a bilateral upper lid bleph, but we routinely do those anyway. Also, plenty of cases of one eye having a severe complication in refractive laser eye surgery have been reported, but we also do those bilaterally. Why the difference with cataract surgery?

Granted, if a perfect refractive outcome is desired, I prefer seeing the first eye’s outcome in predicting the second, although most of the time it wouldn’t have changed the second outcome. But the bigger issue is financial. If your surgery center overhead is 75% and you take a 50% cut on the second eye, you’ve arguably made zero profit doing both eyes on the same day! (Yes, there are other considerations, but you get my point.) Besides the owners’ desire for profit, we have a fiduciary responsibility to our staff. If Medicare and others changed that 50% cut to 10% or 20%, we might see a much greater transition to bilateral surgery, and it would save the government and other insurers a lot of money as well.

USE YOUR JUDGEMENT

Regarding these two issues and my practice: I routinely treat close friends and family. It’s a rural area, so there really aren’t a lot of other choices. I’d rather treat them, and they’d prefer me as their doctor.

As to same-day cataract surgery, for now we limit that mostly to patients who have no insurance and pay out of pocket. We offer a discount to these patients if they wish to have bilateral surgery, which they choose almost 100% of the time even after being told potential risks.

I feel very comfortable with the choices I’ve made, although others might respectfully disagree.

How comfortable? About 2 years ago my brother, 49, and my father, 84, both developed cataracts. I performed bilateral same-day cataract surgery on each of them, back to back, the same day. My brother got bilateral Symfony (Johnson & Johnson Vision) lenses (this was before we were using mix and match), and my father, who is suffering with Alzheimer’s, received bilateral monofocal lenses. Both had outstanding results and are quite happy with their outcomes.

Stupid? Arrogant? Doing what my well-informed and fully consented family preferred? I’ll let you be the judge of that. OM

Larry E. Patterson, MD, is an instrument-rated private pilot. He is also the chief medical editor of Ophthalmology Management. On the side, he is the founding partner of Eye Centers of Tennessee. His e-mail is larryp@ecotn.com.