To Treat or not to treat?

A health care reform debate

J. Alberto Martinez, M.D.

Case presentation.

HistoryRS is an 85 Y.O. male referred emergently by an ophthalmologist for a severe corneal ulcer, left eye.

CC: Seven day history of decreased vision and discharge, left eye. Denies pain.

Patient is on his last few radiation treatments for throat cancer.

Mr. RS lives with a septuagenarian couple who are his friends and help take care of him.

Patient still smokes ½ pack of cigarrettes per day

EXAMFragile, cachectic male able to ambulate slowly.

Able to cooperate, slowly, grumpily.

VA: OD: sc 20/25 OS: sc: HM

Poor blink OU

Normal anterior segment OD, well centered IOL

OS: Massive corneal infiltrate with bulging cornea. No seidel’s, deep anterior chamber, pseudophakic.

Diagnosis and Treatment

Corneal ulcer, severe, probably associated with exposure keratopathy

TREATMENT?

Initial TreatmentCorneal scraping for culture and sensitivity

Start VigamoX every 1 hour around the clock until fortified antibiotics ( Ancef and Gent) obtained. Shield

Assesed home condition, spoke with social worker, home friends to improve compliance, given patient’s general condition.

Daily follow-up.

Clinical EvolutionInfiltrate appeared to get smaller over the next three days. Compliance appeared to be good. Difficulties with transportation.

Cultures were negative.

On the fourth day, the chamber collapsed

Now What?To transplant or not?

No transplant: Ulcer may be sterilized, perforation would be vascularized, eye would eventually may become pthisical.

Transplant: 90% plus chances of saving the eye and eventually good vision.

Patient given the option: “he wants his eye”

ETHICSShould we invest about $10,000 on this eye?

Patient’s quality of life would be essentially unchanged with a successful transplant.

Cost to SOCIETY.

Treatment

Treatment

DiscussionUtilization of limited health care resources

Who makes the decision?